PRACTICAL   TREATISE 


TUMORS  OF  THE  MAMMAM  GLAND: 


HISTOLOGY,  PATH 


NOSIS,  AND  TREATMENT. 


SAMUEL  W.  GROSS,  A.  M.,  M.  D., 


SURGEON  TO,   AND  LECTURER  ON  CLINIC;^ 
COLLEGE   HOSPITAL   AND   THE   PHILADJ 
PATHOLOGICAL    SOCIETY   OF   PHILAI 
MERLT  MUTTER  LECTURER  ON 
COLLEGE  OF  PHYSICIANS 

01"    THE    ACADEMY'^ 
PHLLADELI 


jrqert  in,  the  jefferson  medical 
lia  hospital  ;  president  of  the 
lphia  ;  fellow  of,  and  fob- 
sgical  pathology  in,  the 
iiladelphia;  fellow 
surgery  of 

,   ETC.  • 


ILLUSTRA 


NINE  ENGBAVINGS. 


NEW  YORK 

D.   APPLETON   AND    COMPANY, 

1,  3,  AND   5   BOND  STREET. 

1880. 


COPTEIGHT   BT 

D.    APPLETON   AND   COMPANY, 

1880. 


inoinedical 
Library 

-tic 


TO 

SAMUEL  D.  GROSS,  M.  D.,  LL.  D.,  D.  0.  L.  Oxoif., 

PROFESSOR  OP  SURGERY  IN  THE  JEFFERSON  MEDICAL  COLLEGE, 

THIS     VOLUME, 

DESIGNED    TO    EECONCILE    THE    CLINICAL    FEATURES    AND    THE    MINUTE 

8TEU0TUEE   OF    TUMORS   OF   THE   MAMMARY    GLAND, 

IS    AFFECTIONATELY    INSCRIBED 

BY   HIS   SON, 

THE  AUTHOR. 


706'^85 


PREFAO  E. 


MoDEEisr  liistolo2fical  researclies  have  so  com- 
pletely  revolutionized  our  knowledge  of  the  various 
new  formations  that,  so  far  as  I  know,  tumors  of  the 
mammary  gland  have  not,  up  to  the  present  time, 
constituted  the  subject  of  a  systematic  and  strictly 
accurate  treatise.  To  fill  this  void,  I  have  studied 
their  minute  structure,  investigated  their  general 
pathology,  and  applied  the  principles  which  are 
fairly  deducible  from  their  anatomy  and  their  his- 
tory to  their  differential  diagnosis  and  to  their  ration- 
al treatment.  As  the  deductions  founded  upon  the 
older  statistics  are  of  little  or  no  value,  I  have,  with 
the  view  of  harmonizing  structural  with  clinical  ob- 
servations, examined  the  entire  subject  anew,  and 
have  carefully  analyzed  sixty-five  cases  of  cysts  and 
nine  hundred  and  two  neoplasms,  the  nature  of 
which  has  been  confirmed  by  the  microscope,  and 
more  than  one-seventh  of  which  are  original. 


vi  PREFACE. 

Not  the  least  important  part  of  the  work  is  that 
in  which  the  view  is  sought  to  be  maintained  by  an 
abundant  array  of  facts,  that  carcinoma  may  be  per- 
manently relieved  by  thorough  operations  practised 
in  the  early  stage  of  its  evolution.  I  am  aware  that 
this  doctrine  will  not  meet  with  general  acceptance 
on  the  part  of  those  purely  mechanical  surgeons  who 
believe  that  freedom  from  recurrence  denotes  an  in- 
nocent neoplasm.  In  every  case  of  final  recovery 
mentioned  in  this  treatise,  however,  the  diagnosis 
was  based  upon  minute  examinations  conducted  by 
trustworthy  microscopists,  whose  reports  have  been 
utilized  in  this  inquiry  to  the  exclusion  of  the  de- 
scriptions of  the  early  writers  on  carcinoma. 

To  place  the  subject  of  tumors  of  the  mammary 
gland  in  the  clearest  possible  light,  and  to  afford  ma- 
terial assistance  in  their  differentiation,  I  have  inter- 
spersed through  the  text  drawings  of  their  minute 
features,  made,  mth  the  aid  of  the  camera,  princi- 
pally from  my  own  specimens,  so  as  to  leave  no 
doubt  as  to  their  true  nature.  For  all  of  these 
drawings,  mth  the  exception  of  figs.  2  and  6,  which 
are  from  the  pencil  of  Assistant-Sui'geon  W.  B.  Brews- 
ter, U.  S.  Army,  and  of  fig.  10,  which  was  kindly 
furnished  me  by  Dr.  W.  B.  Nancrede  of  this  city, 
I  am  indebted  to  Dr.  E.  O.  Shakespeare,  one  of 
the  accomplished  translators  of  Cornil  and  Ranvier's 
"Manual  of  Pathological  Histology."      For   figs.  3, 


PREFACE.  vii 

4,  and  25,  taken  from  wet  specimens,  I  have  to 
express  my  obligations  to  Dr.  S.  E.  James,  formerly 
Resident  Physician  in  the  Jefferson  Medical  College 
Hospital.  The  remaining  illustrations  are  from  pho- 
tographs of  my  private  and  public  cases. 

S.  W.  Geoss. 

1112  Walnut  Street,  Philadelphia,  June,  1880. 


CONTENTS, 


FAQE 

CHAPTER   I. 

Classification  and  Relative  Frequency  of  Tumors  of  the  IIamma      .       1 


CHAPTER   II. 

Etolution  and  Transformation  of  Mammary  Neoplasms        .        .        .12 

CHAPTER   III. 
Etiology  of  Neoplasms  of  the  Mamma 25 

CHAPTER  rV. 

The  Anatomy  of  the  Connectite  Tissue  Neoplasms       .        .        .        .36 

CHAPTER  V. 
Fibroma 49 

CHAPTER  VI. 
Sarcoma 65 

CHAPTER  VII. 
Myxoma 101 

CHAPTER  VIII. 
Adenoma HO 

CHAPTER  IX. 
Carcinoma 124 

CHAPTER  X. 
Cysts 183 


X  CONTENTS. 

PAGE 

CHAPTER  XI. 

The  Diagnosis  of  Tumors  of  the  Mammary  Gland        .        .        .        .197 

CHAPTER  Xn. 
The  Treatment  of  Tumors  of  the  Mammary  Gland       .        .        .        .216 

CHAPTER  XIII. 
Tumors  of  the  Male  Mammary  Gland 237 


LIST   OF  ILLUSTRATIONS. 


FIG.  PAGE 

1.  Cystic  Fibroma Original    40 

2.  Cystic  Fibroma "  41 

3.  Intracanalicular  Fibroma "  42 

4.  Intracanalicular  Fibroma "  42 

5.  Intracanalicular  Fibroma "  43 

6.  Fibroma ! "  51 

1.  Small  Round-Celled  Sarcoma "  67 

8.  Lymphoid  Sarcoma "  68 

9.  Small  Spindle-Celled  Sarcoma "  69 

10.  Large  Spindle-Celled  Sarcoma "  10 

11.  Giant-Celled  Sarcoma "  VI 

12.  Myxomatous    and   Telangiectatic   Cystic    Small  Spindle-Celled 

Sarcoma "  83 

13.  Hyaline  Myxoma "        102 

14.  Tubular  Adenoma "        112 

15.  Cystic  Acinous  Adenoma From  Rindfleisch  114 

16.  Cystic  Tubular  Adenoma Original  116 

1*7.  Development  of  Carcinoma "        127 

18.  Extension  of  Carcinoma  into  the  Great  Pectoral  Muscle "        129 

19.  Fibrous,  or  Scirrhous,  Carcinoma "        130 

20.  Atrophying  Scirrhus "        131 

21.  Atrophying  Scirrhus '         132 

22.  Encephaloid  Carcinoma 133 

23.  Encephaloid  Carcinoma "        134^ 

24.  Colloid  Carcinoma From  Rindfleisch  135 

25.  Cystic  Encephaloid  Carcinoma Original  137 

26.  Disseminated  Simple  Carcinoma "        149 

27.  Local  Dissemination  and  Ulceration  of  Scirrhous  Carcinoma. . .       "        152 

28.  Extension  of  Carcinoma  into  the  Lymph  Spaces. 

From  Comil  and  Ranvier  156 

29.  Atrophying  Scirrhus  of  the  Right  Mammary  Gland Original  180 


A.  PRACTICAL  TREATISE 


ON 


TUMORS  OF  THE  MAMMARY  GLAND. 


CHAPTEK    I, 


CLASSIFICATION  AND   RELATIVE  FBEQUENCT  OF  TUMORS  OF 
THE  MAMMA. 

Tumors  of  the  mammaiy  gland  include  neoplasms 
and  cysts.  The  former  are  morbid  additions  to,  or 
rather  overgrowths  of,  the  component  tissues  of  the 
organ,  and  represent  an  excess  of  normal  develop- 
ment and  growth.  They  are  products  of  the  same 
formative  laws  as  the  healthy  structures,  and/ are 
subject  to  the  same  physiological  laws,  which  not 
only  preside  over  the  evolution  of  the  latter,  but  ^^^"u^C^jj 
likewise  regulate  their  renewal  and  their  degenera-  ,.t  ^  Tt>  <^ 
tions.  -  Unlike  the  inflammatory  new  formations,  they 


.^.'£ 


persist  and  increase ;  and  they  possess  an  individu-  J 
ality  of  their  own,  as  is  evinced  by  their  growing  ^7\> 
irrespective  of  the  gland  itself,  and,  in  certain  in-  ^  ^  ^ 
stances,  by  reproducing  their  like  in  the  contiguous  TA'*^  ^^ 
and    associated    structures    and    in    distant    organs.  ',^^ 

Cysts,  on   the   other   hand,  with   the   exception   of   .  » 

those  which  surround  hydatids,  are  not  new  forma-/*''*'^^^ 


2  TUMORS  OF  THE  MAMMARY  GLAND. 

tions,  but  result  merely  from  ectasia  or  dilatation, 
and  the  retention  of  tlie  secretion,  of  tlie  lacteal 
glands  and  of  their  ducts. 

Up  to  a  comparatively  recent  period  tlie  non- 
carcinomatous  neoplasms  of  tlie  breast  were  univers- 
ally described,  and  are  still  ranked  in  standard  works 
on  surgery,  and,  to  a  less  extent,  on  pathological 
anatomy,  or  labeled  in  our  museums,  as  adenoma,  or 
under  some  of  its  various  synonyms,  as  adenocele, 
adenoid  tumor,  proliferous  mammary  cyst,  mammary 
glandular  tumor,  or  partial  glandular  hypertrophy  or 
hyperplasia.  These  terms  would  naturally  induce 
one  not  acquainted  with  modern  histological  research 
to  conclude  that  tumors  developed  at  the  expense  of 
the  secreting  structure  were  so  excessively  common 
as  to  constitute  the  majority  of  the  so-called  benign 
growths,  when,  in  point  of  fact,  under  these  names 
are  included  formations  which  differ  widely  in  their 
genesis,  intimate  nature,  and  clinical  features. 

This  confusion  originated  mainly  with,  and  was 
perpetuated  by,  Mr.  Birkett,'  who,  in  confirming  the 
pre\dous  observations  of  Lebert ""  on  the  presence  of 
acini  and  ducts  in  mammary  growths,  taught  that 
the  former  were  of  new  formation,  and  consequently 
called  the  tumors,  which  were  previously  kno^vn  as 
pancreatic  sarcoma,^  chronic  mammary  tumor,*  fibro- 
cellular  hypertrophy,"  and  fibrous  bodies,*  lobular 
iraperfect    hypertrophies,    a    term   which    he    soon 

1  Tlie  Diseases  of  the  Breast,  p.  124,  1850. 

^  Physiologie  Patholocfique,  vol.  ii,  pp.  193-202,  1845. 

'  Abernethy,  An  Attempt  to  form  a  Classification  of  Tumors,  1804. 

*Sir  Astley  Cooper,  Illustrations  of  the  Diseases  of  the  Breast,  p.  54,  1829. 

*  Velpeau,  Diet,  de  Medecine,t.  xix,  art.  "  Mamelle,"  1839. 

^  Cruveilbier,  Bull,  de  VAcad.  Roy.  de  Jledecine,  t.  ix,  p.  330,  1844. 


classification:  3 

dropped  for  adenocele/  wliich,  in  its  turn,  was  re- 
placed by  adenoma,  to  whicli  lie  still  adheres  in 
his  latest  publications.*  From  the  great  importance 
which  he  attached  to  the  discovery  of  acini  in  these 
neoplasms,  through  which  they  bear  a  certain  resem- 
blance to  the  structure  of  the  normal  mamma,  the 
other  constituents  which  enter  into  their  composition 
were  thought  so  lightly  of  that  they  were  not  consid- 
ered in  determining  their  nature ;  and  to  such  an  ex- 
tent did  his  and  Lebert's  doctrines  influence  con- 
temporaneous wi'iters  that,  in  describing  mammary 
tumors  for  the  most  part  as  adenoid,  we  have  been 
deprived  of  an  immense  mass  of  material  which 
would  otherwise  have  proved  invaluable  in  an 
analytical  study  of  the  non-carciuomatous  growths. 
Hence  it  is  that,  with  few  exceptions,  I  cannot  avail 
myself  of  the  one  hundred  and  twenty-five  cases  of 
adenoma  recorded  and  analyzed  by  Birkett,'  nor  of 
the  eighty-one  examples  of  adenocele  of  Bryant,*  nor 
of  the  observations  of  Paget,^  Velpeau,°  and  Broca.^ 

While  it  is  true  that  hyperplasia  of  the  glandular 
tissue  of  the  breast  may  be  so  excessive  as  to  consti- 
tute the  tumor  known  as  adenoma,  this  occurrence  is 
so  rare  that  true  adenomata  must  be  ranked  among 
the  most  infrequent  of  neoplasms.  In  all  of  the  con- 
nective tissue  tumors  the  lacteal  glands,  although  their 
epithelium  may  be  in  a  state  of  irritation,  generally 

'  Guy^s  Hosp.  Reps.y  ser.  3,  vol.  i,  p.  131,  1855. 

2  Holmes's  System  of  Surgery,  2d  ed.,  vol.  6,  p.  255,  1871. 

^  Ante. 

4  The  Practice  of  Surgery,  Phila.,  1879,  p.  685. 

*  Lectures  on  Surgical  Pathology,  2d  ed.,  pp.  427  and  569. 

®  Traite  des  Maladies  du  Sein,  p.  416,  1854. 

'  Traite  des  Tumcurs,  t.  ii,  p.  413,  1869. 


4  TUMORS  OF  TEE  MAMMARY  GLAND. 

remain  passive,  and  as  tlie  growtli  advances  tliey  may 
disappear  to  such  an  extent  as  to  be  scarcely,  if  at 
all,  recognizable.  Instead,  therefore,  of  being  newly 
formed  and  predominant,  the  secreting  elements  are 
really  merely  accessory  or  accidental,  and  represent 
the  remains  of  old  or  preexisting  glands  contained, 
but  widely  separated,  in  a  fibromatous,  sarcomatous,  or 
myxomatous  stroma.  At  the  present  day,  therefore, 
we  hear  less  of  adenoma  than  foiTQerly,  an  advance 
for  which  we  are  mainly  indebted  to  Billroth,'  Vir- 
chow,'  Cornil  and  Kanvier,"  Monod,*  and  Labbe  and 
Coyne ; "  although  Billroth,"  Klebs,'  Duplay,'  Green," 
and  Wilks  and  Moxon,"  and  others  prefix  the  term  ad- 
eno  to  these  tumors  to  indicate  the  persistence  of  more 
or  less  modified  glandular  tissue.  From  the  fact,  how- 
ever, that  nearly  all  the  histoid  mammary  tmnors  are 
mixed,  in  the  sense  of  their  including  glandular  struc- 
ture, and  from  the  circumstance  also  that  the  recur- 
rent growths  are  devoid  of  acini  and  ducts,  if  the 
entire  breast  has  been  removed,  the  term  adeno  is  a 
misnomer,  and  should  no  more  be  applied  to  a  tumor 
of  the  mamma  than  a  sarcoma  of  a  bone  should  be 
called  an  osteosarcoma,  or  a  sarcoma  of  a  muscle  a 
myosarcoma. 

'  Virchoiv's  Archiv,  Bd.  xviii,  p.  51,  1860. 

*  Die  Krankhafte  Geschwillsie,  chapters  on  fibroma,  myxoma,  and  sarcoma, 
1864. 

^  Manuel  d'Histologie  Path.,  pp.  127,  151,  160,  and  292,  1869. 

*  Arch.  Gen.  de  Med.,  ser.  6,  t.  xxv,  p.  22,  18*75. 
^  Traite  des  Tumeurs  Benignes  du  Scin,  1876. 

«  Ante;  and  Chir.  Klinik,  Wien,  1871-'76,  pp.  261-263. 
'  Hdbch.  do-  Path.  Anai.,  Bd.  i,  Abth.  1,  p.  1199,  1876. 
^  Traite  Element,  de  Path.  Externe,  par  FoUin  ot  Duplay,  t.  v,  p.  615  et  seq., 
1878. 

'  Pathology  and  Morbid  Anatbmy,  p.  140,  Phila.,  1876. 
'0  Lectures  on  Path.  Anatomy,  2d  ed.,  p.  583,  1875. 


CLASSIFICATION.  5 

Wliile  Lebert,  and  Bii'kett,  and  tlieir  followers 
were  T\Tong  in  regarding  the  glandular  constituents 
as  tlie  essential  elements  of  the  non-carcinomatous 
neoplasms,  their  investigations  were  of  great  value  in 
confinning,  with  the  aid  of  the  microscope,  the  view 
of  Sii'  Astley  Cooper,  that  there  is  a  class  of  growths 
entii^ely  distinct  from  carcinoma.  Had  they  only 
paid  the  same  amount  of  attention  to  the  fibrous 
element  of  the  breast  as  a  source  of  the  new  foima- 
tions  as  they  did  to  connective  tissue  elsewhere,  they 
would  readily  have  understood  why  it  is  that  among 
the  so-called  benign  growths  some  are  perfectly  inno- 
cent, while  others  reproduce  themselves  locally  after 
removal,  and  others  give  rise  to  metastatic  deposits 
in  distant  organs. 

Almost  as  much  confusion  exists  among  pure  clini- 
cians in  regard  to  the  epithelial  formations.  Medul- 
lary, colloid,  and  withering  carcinoma  are  so  constant- 
ly confounded  mth  meduUaiy  sarcoma,  myxoma,  and 
contracting  fibroma,  and  the  converse,  that  it  is  impos- 
sible to  find  an  accurate  and  complete  account  of  these 
affections  in  any  work  with  which  I  am  acquainted. 
True  adenoma,  which  has  only  recently  emerged  from 
the  obscurity  which  surrounded  it,  is  also  in  danger 
of  being  misunderstood  in  consequence  of  being  de- 
scribed as  epithelioma  by  several  French  ^vriters. 

In  their  anatomical  construction  many  of  the 
mammary  tumors  closely  resemble  the  normal  tissues. 
In  some  examples,  as  in  fibroma,  the  likeness  is  al- 
most perfect,  while  in  others  the  disposition  of  their 
constituents,  modified  as  they  frequently  are  by  cer- 
tain transformations  or  combinations,  is  so  unlike  the 
normal  anatomical   construction   that  the   similarity 


6  TUMOES  OF  TEE  MAMMAE  Y  GLAND. 

amounts  merely  to  a  bad  mimicry.  In  point  of  fact, 
they  are  physiologically  and  structurally  atypical,  in 
that  the  tissues  of  which  they  are  comjDosed  perfonn 
no  functions,  and  are  arranged  differently  from  the 
natural  standard.  A  pure  adenoma,  for  example,  is 
made  up  of  newly  formed  acini,  but  these  are  never 
aggregated  into  lobules  attached  to  excretory  ducts ; 
while  nothino;  could  deviate  more  from  the  normal 
type  than  a  carcinoma.  Hence,  in  classifying  the 
neoplasms  of  the  mamma,  instead  of  adhering  to  the 
modern  custom  of  saying  that  they  are  formed  upon 
the  type  or  model  of  certain  tissues,  it  strikes  me 
that  it  is  far  more  philosophical  to  divide  them  in 
accordance  with  their  origin  from  the  lacteal  glands 
or  the  periglandular  connective  tissue,  and  at  the 
same  time  to  designate  the  tissue  of  which  they  are 
composed,  making,  however,  a  separate  group  of 
cysts,  which  originate  in  a  different  way.  For  these 
reasons  I  prefer  the  following  combined  genetic  and 
anatomical  classification : 

A. 

1.  Neoplasms  derived  from  the  periglandular 
connective,  and  constituted  by  connective  tissue  or 
its  equivalents,  of  which  two  divisions  may  be  made, 
namely — 

a.  Those  which  represent  perfected  or  mature 
connective  tissues,  and  may,  therefore,  be  called  typi- 
cal These  comprise  fibroma,  or  fibrous  tumor ;  myx- 
oma, or  mucous  tumor  ;  lipoma,  or  fatty  tumor  ;  and 
chondroma,  or  cartilaginous  tumor. 

b.  The  second  division  includes  those  neoplasms 
which   represent   embryonic,  umipe,  or  transitional 


CLASSIFICATION.  *l 

connective  tissue,  and  may  be  teimed  atypical.     It  is 
limited  to  tlie  genus  sarcoma. 

2.  Neoplasms  wliicli  proceed  from  tlie  secreting 
elements,  and  are  composed  of  epitlielium.  Of  these, 
adenoma,  or  glandular  tumor,  is  a  typical  epithelial 
growtli,  while  carcinoma  is  an  atypical  epithelial  for- 
mation. 

3.  Neoplasms  which  are  derived  from  and  are  con- 
stituted by  higher  structures.  These  are,  first,  an- 
gioma, or  a  tumor  composed  of  bloodvessels ;  and, 
secondly,  neuroma,  or  a  growth  made  up  of  nerves. 

B. 

Cysts,  which  include  the  formations  due  to  ob- 
struction of  the  ducts  and  the  accumulation  of  the 
secretion  of  the  lacteal  glands,  and  cysts  of  new  for- 
mation inclosing  echinococci. 

In  the  preceding  paragraphs  I  have  used  the  ex- 
pressions typical  and  atypical,  which  are  synonymous 
with  homologous  and  heterologous  of  the  older  pathol- 
ogists, and  with  the  terms  benign  and  malignant  of 
the  clinicians.  In  the  typical  growths,  a  determined 
model  is  followed,  so  that  there  is  a  tumor-like  repro- 
duction of  adult  connective  tissue  or  epithelial  ele- 
ments. In  the  atypical  neoplasms,  on  the  other 
hand,  the  constituents  either  extend  beyond  their 
normal  boundaries,  or  deviate  in  form,  size,  and  group- 
ing from  the  mature  epithelial  or  connective  tissue 
textures,  and  represent  iiTegular  proliferations. 

The  genetic  classification  of  neoplasms  has  not 
met  with  general  acceptance  on  the  part  of  writers 
on  and  teachers  of  surgery,  and  many  complain  of  the 


8  TUMORS  OF  THE  MAMMARY  GLAND. 

gradual  abandonment  of  tlie  division  into  benign  and 
malignant,  and  find  special  fault  witli  the  term  sar- 
coma, under  whicli  they  say  pathologists  group  tumors 
which  possess  the  greatest  possible  diversity  of  clinical 
history.  Carcinoma,  however,  is  open  to  the  same 
objection;  and  many  purely  practical  surgeons,  in 
teaching  that  their  benign  growths  are  synonymous 
with  adenoceles,  the  connective  tissue,  or  the  non-car- 
cinomatous  neoplasms,  and  that  the  malignant  ones 
are  equivalent  to  the  carcinomatous  tumors  of  the 
histologist,  hold  a  position  which  is  no  longer  tenable. 
With  the  view  of  including  a  certain  class  of  the  non- 
carcinomatous  group,  which  some  clinicians  recognize 
as  being  partially  malignant,  they  have  coined  a  new 
expression,  and  describe  sarcoma  as  a  semi-malignant 
or  recurrent  growth ;  but  this  clinical  classification  is 
even  worse  than  the  other,  since  sarcoma,  as  may  be 
seen  in  the  chapter  on  that  affection,  is  more  infec- 
tious than  ordinary  scirrhus,  and  only  yields  in  point 
of  malignity  to  medullary  carcinoma.  It  may  be  said, 
however,  that  the  nearer  the  structure  of  a  mammary 
tumor  approaches  that  of  the  physiological  adult  tis- 
sues, whether  these  be  connective  or  epithelial,  tlie 
more  innocent  is  the  growth,  and  that  the  more  it 
departs  from  the  normal  standard,  or  the  more  atypi- 
cal it  is,  the  more  malignant  is  the  new  formation. 
If  the  clinician  wishes  to  retain  his  classification,  he 
should  base  it  upon  the  fact,  disclosed  by  modern 
histological  investigations,  that  tumors  which  origi- 
nate from  the  connective  tissue  have  their  innocent, 
semi-malignant,  and  malignant  representatives,  while 
those  which  are  derived  from  the  epithelial  elements 
include   semi-malignant    and    malignant    formations. 


EELATIVE  FREQUENCY.  9 

Thus,  in  the  former  series,  fibroma,  lipoma,  and  chon-. 
droma_are  absolutely  benign  ;  myxoma  is  semi-malig- 
nant, because  it  exhibits  a  marked  tendency  to  repro- 
duce itseK  after  removal ;  and  sarcoma,  as  I  have  just 
pointed  out,  is  excessively  malignant.  Of  the  epithe- 
lial series,  the  malignant  nature  of  carcinoma  is  famil- 
iar to  every  one,  while  adenoma  is  eminently  a  recur- 
rent growth. 

Of  the  relative  frequency  of  mammary  tumors  it 
is  difficult  to  form  an  estimate  based  upon  accurate 
and  extended  records,  since  surgeons,  for  the  most 
part,  report  their  cases  merely  as  adenoid  and  cancerous. 
The  following  table  of  649  examples,  however,  may 
prove  useful  in  throwing  some  light  upon  this  point. 


AUTHOKITY. 

Carci- 
noma. 

Sar- 
coma. 

Fibro- 
ma. 

Ade- 
noma. 

Cyets. 

Billroth,    Chir.    Klinik,    Zurich,    1860-'67,    and 
Wicn   1868  '69-'70,  and  '71-'76 

245 

15*7 

28 
100 

19 

16 

6 

16 

19 

5 

9 

15 

1 

"i 

8 

Langenbeck,  Virchoiv^s  Archiv,  Bd.  xviii,  p.  51,  and 

Langenbeck''s  Archiv,  Bd.  xxi,  Suppt.  p.  149.  . , 

Kuester,  Langenhech's  Archiv,  Bd.  xii,  p.  616. . .  . 

S.  W.  Gross,  Private  Notes 

2 
3 
4 

530 

57 

48 

2 

12 

Excluding  cysts,  which  constitute  only  one  out  of 
every  fifty-four  tumors,  it  will  be  seen  that  of  637 
neoplasms,  530,  or  83-20  per  cent.,  were  carcinomatous, 
and  107,  or  16*79  per  cent.,  were  non-carciuomatous. 
This,  doubtless,  is  the  true  proportion,  as  I  find  that 
Bryant*  records  400,  or  83-16  per  cent.,  of  carcino- 
mata,  against  81,  or  16*83  per  cent.,  of  adenoceles, 
which  are  equivalent,  according  to  his  views,  to  the 
non-carcinomatous  growths.  Labbe  and  Coyne  give 
the  details  of   eight  sarcomata,  eighteen  fibromata, 

'  Op.  cif.,  pp.  685  and  689. 


10  TUMORS  OF  TEE  MAMMARY  GLAND. 

two  adenomata,  and  one  myxoma.  Adding  these  to 
the  cases  in  the  table,  for  the  purpose  of  establishing 
the  relative  frequency  of  the  non-carcinomatous  new 
formations,  w^e  have  136  tumors,  of  which  QtQ,  or  48*52 
per  cent.,  are  fibromata,  65,  or  47*79  per  cent.,  are 
sarcomata,  4,  or  2*94  per  cent.,  are  adenomata,  and  1, 
or  less  than  1  per  cent.,  is  a  myxoma. 

As  will  have  been  noticed,  lipoma  and  chondroma 
find  no  place  in  the  table.  While  examples  of  fatty 
tumor,  developed  in  the  paramammary  adipose  tissue, 
are  recorded  by  Warren,*  Brodie,"  Velpeau,"  Cooper,* 
Koper,"  and,  more  recently,  by  Billroth '  and  Bryk,' 
I  am  not  aware  of  a  single  case  of  circumscribed  lipo- 
ma occurring  in  the  gland  itself.  Sir  Astley  Cooper  * 
and  Cruveilhier  *  have  each  described  an  instance  of 
cartilaginous  growth ;  but,  in  the  absence  of  minute 
examination  in  the  one,  and  of  a  complete  account  in 
the  other,  as  well  as  of  any  new  examples,  the  fact, 
to  say  the  least,  is  very  doubtful.  Of  the  neoplasms 
originating  from,  and  composed  of  higher  tissues,  Tri- 
pier"  records  two  instances  of  amyelinic  neuroma, 
while  Bryant "  briefly  notes  a  vascular  tumor  of  the 
mamma,  and  Image  "  and  Conrad  Langenbeck  "  have 

'  Surgical  Observations  on  Tumors,  p.  228. 

*  Led.  on  Surg.  Path.,  p.  271. 
3  Op.  cit.,  p.  247. 

*  Op.  cit.,  p.  67. 

*  Holmes's  S'/sfem  of  Surgernf,  2d  ed.,  vol.  v,  p.  267. 

«  Fitha  and  Blllroth's  Hdbch.,  Bd.  iii,  Abth.  2,  Lief,  i,  p.  85. 
'  LangcnhecJc's  Archiv,  Bd.  xvii,  pp.  576  and  580. 

*  Op.  cit.,  p.  47. 

9  Traiie  d'Anaf.  Path.,  t.  iii,  p.  824. 

"*  Lid.  Encijclop.  dcs  Sciences  Med.,  ser.  2,  t.  iv,  p.  408. 

"  Op.  cit.,  p.  692. 

12  Med.-Chir.  Trans.,  vol.  xxx,  p.  109. 

1*  Nosologie  und  Therapie  der  Chir.  Krankkeiien,  Bd.  v,  p.  83. 


RELATIVE  FREQUENCY.  \\ 

reported  similar  growths,  wMcli  had  extended,  how- 
ever, from  the  skin  to  the  mamma  itself.  Hence,  in 
speaking  hereafter  of  the  connective  tissue  neoplasms, 
I  wish  to  be  understood  as  referrins-  to  fibroma,  sar- 
coma,  and  myxoma  alone,  and  to  these  gro\\i;hs,  along 
mth  adenoma,  when  alluding  to  the  non-carcinoma- 
tous  group. 


CHAPTER    II. 

THE  EVOLUTION  AND    TRANSFORMATION   OF  MAMMARY 
NEOPLASMS. 

The  development  and  growtli,  or  evolution,  of  the 
new  formations  of  the  mamma  include  processes 
which  are,  on  the  one  hand,  purely  theoretical,  and, 
on  the  other,  strictly  practical.  Whether  of  epithe- 
lial or  connective  tissue  derivation,  they  all  originate 
through  the  multiplication  or  proliferation  of  the  pre- 
existing cells  of  the  lacteal  glands  or  the  stroma,  and 
their  descendants,  either  through  direct  hypei'plasia 
and  the  primary  production  of  the  typical  forms  of 
the  mother  tissue,  or  after  the  model  of  embiyonic 
tissue  formation.  The  latter  plays  a  more  important 
role  than  the  former,  since  through  it  nearly  all  the 
neoplasms  may  arise.  Just  as  in  the  embryo  all  tis- 
sues originate  from  masses  of  indifferent  formative 
cells  which  have  proceeded  from  the  ]3rimordial  cell, 
so  in  this  mode  of  the  development  of  tumors,  the  tis- 
sues arise  from  collections  of  small,  round,  indifferent 
cells,  which  resemble  those  of  the  embryo  or  those  of 
gi'anulations.'  In  the  next  stage,  these  cells  are  con- 
verted into  the  tissues  of  which  the  tumor  is  com- 
posed, and  the  tyj^e  followed  here  is  the  same  as  that 
which  prevails  in  foetal  development. 

'  Compare  with  Virchow,  Cellularpathologie,  4th  ed.,  chapter  xx ;  Geschwicl- 
sie,  Bd.  1,  p.  89 ;  and  Archiv,  Bd.  Ixxix,  p.  193.  ' 


EVOLUTION.  13 

In  the  preceding  chapter  I  divided  the  neoplasms 
of  the  mamma  in  accordance  with  their  derivation 
from  the  glandular  or  periglandular  constituents  of 
the  orcran.  While  this  view  of  their  histoo-enesis  is 
most  simple,  and  involves  the  belief  that  epithelium 
alone  produces  epithelium,  and  that  connective  tissue 
arises  solely  from  connective  tissue  elements,  every 
one  who  is  at  all  familiar  with  investigations  in  this 
direction  is  aware  that  the  origin  of  some  of  the  new 
growths  is  still,  and  will  probably  always  be,  a  dis- 
puted point,  and  it  is  for  this  reason  that  I  cannot 
overlook  the  contradictory  statements  which  prevail 
on  the  development  of  neoplasms,  and  which  involve 
the  question  whether  a  cell  belonging  to  a  certain 
class  can  be  the  offspring  of  a  cell  belonging  to  an 
entirely  different  system. 

Up  to  a  quite  recent  date  the  origin  of  the  con- 
nective tissue  neoplasms  appeared  to  be  settled  be- 
yond the  possibility  of  refutation,  and  carcinoma  was 
the  only  debatable  ground;  but  the  researches  of 
Creighton,  which  will  be  briefly  explained  presently, 
have  not  only  opened  up  a  new  field  of  speculative 
inquiry,  but  threaten  to  overturn  the  generally  ac- 
cepted theory  as  to  the  development  of  the  mamma. 

With  regard  to  carcinoma,  Virchow  and  his  school, 
which  includes  many  noted  observers  in  Germany, 
Cornil  and  Ranvier,  Tripier,  and  Labbe  and  Coyne 
in  France,  and  Wilks  and  Moxon  in  England,  hold 
that  it  originates  from  the  fixed  connective  corpus- 
cles, or,  as  they  are  now  known,  the  endothelial  cells 
of  that  tissue,  which  undergo  a  change  of  type  in 
their  multiplication,  so  that  the  cells  are  of  hetero- 
plastic origin  in  contradistinction  to  the  cells  of  ade- 


14  NEOPLASMS  OF  THE  MAMMAE  Y  GLAND. 

noma,  for  example,  whieli  merely  rej)resent  a  hyper- 
plasia, or  simple  numerical  increase,  of  tlie  cells  of  tlie 
acini.  In  accordance  with  this  doctrine,  the  carcino- 
matous bodies,  nests,  plugs,  or  cylinders,  subsequently 
break  thi'ough  the  enlarged  acini,  fuse  with  the  epi- 
thelial cells,  and  in  this  way  destroy  the  glandular 
stinicture  of  the  breast. 

The  derivation  of  carcinoma  from  the  connective 
tissue  cells  is  held  in  a  modified  form  by  Von  Reck- 
linghausen and  Koester,  who  trace  its  genesis  to  the 
proliferation  of  the  endothelium  of  the  lymphatics, 
which  is  the  histological  equivalent  of  the  connective 
tissue  corpuscle.  The  transformed  endothelium  ex- 
tends, as  plugs,  into  the  lymph  spaces,  converting 
the  cells  present  in  them  into  epithelial  cells,  and 
finally  encroaches  upon  and  demolishes  the  lacteal 
glands. 

In  opposition  to  these  \news,  Billroth,  "VValdeyer, 
Langhans,  Liicke,  Rudnew,  and  Lancereaux  contend 
that  the  epithelial  cells  of  the  new  growth  are  due 
exclusively  to  the  continuous  multiplication  of  the 
preexisting  epithelium,  and  they  base  their  deduc- 
tions, not  only  upon  direct  observation,  but  upon  the 
generally  accepted  histogenetic  law  that,  after  the 
differentiation  of  the  segmentation  spheres  into  the 
blastodermic  layers,  epithelial  cells  are  the  lineal  de- 
scendants of  epithelial  germs  alone,  and  connective- 
tissue  corpuscles  of  connective  tissue  germs  alone; 
and  they  argue  that  the  same  law  is  in  force  in  the 
pathological  development  of  cells  in  post-embryonal 
life. 

Other  investigators  are  more  conservative,  -  since 
they  refer  mammary  carcinoma  to  two  sources,  name- 


EVOLUTION.  15 

ly,  primary  proliferation  of  tlie  cells  of  tlie  acini,  and 
secondary  infection  of  tlie  cells  of  tlie  stroma  by  the 
altered  epithelial  elements. 

In  the  study  of  the  elements  which  are  preseut  in 
carcinoma,  in  addition  to  the  epithelial  cells,  one  has 
to  consider  the  broods  of  young  cells  which  infiltrate 
the  periglandular  connective  tissue,  and  which  im- 
part to  the  picture  an  appearance  that  is  scarcely 
to  be  distinguished  from  irritative  or  chronic  inflam- 
matoiy  processes.  Y/hether  this  small-celled  infil- 
trate, which  plays  so  important  a  part  in  the  subse- 
quent growth  and  local  extension  of  carcinoma,  is 
coincident  with  the  proliferation  of  the  epithelial 
cells ;  whether  it  precedes  and  occasions  the  latter ; 
or  whether  it  is  induced  by  the  growth  of  the  epithe- 
lium into  the  contiguous  stroma,  are  points  which  are 
as  yet  unsettled.  It  is,  moreover,  not  at  all  clear 
whether  it  represents  mobilized  connective  tissue  cor- 
puscles, or  emigrant  white  blood  corpuscles,  or  young 
epithelial  elements  which  have  wandered  out  of  the 
enlarged  acini. 

However  this  may  be,  Klebs,  Rindfleisch,  RudoK 
Maier,  Birsch-Hirschfeld,  Neumann,  Thin,  Creighton, 
and  Woodward,  while  supporting  the  epithelial  origin 
of  carcinoma,  are  convinced  that  the  small  cells  of 
the  stroma  are  metamorphosed  into  epithelial  ele- 
ments by  contact,  or  by  what  is  termed  epithelial 
infection  or  inoculation,  as  is  assumed  to  be  witnessed 
in  the  physiological  reproduction  of  epithelium,  and 
in  the  healing  of  wounds  and  ulcers,  and  not  through 
any  independent  action  of  their  own,  as  is  claimed  by 
those  pathologists  who  maintain  the  connective  tissue 
origin  of  carcinoma.     Just  precisely  how  this  epithe- 


16  NEOPLASMS  OF  THE  MAMMARY  GLAND. 

lial  infection  takes  place,  and  what  is  infected,  are  as 
yet  matters  of  doubt.  Rindfleiscli  and  Klebs  teacli 
that  the  epithelial  cells  leave  the  acini  bodily,  wan- 
der into  the  interspaces  of  the  connective  tissue,  and 
infect  the  cells  present  in  that  structure,  which  they 
look  upon  as  connective  tissue  corpuscles,  but  which 
Doutrelepont,  Thin,  and  Woodward  regard  as  being 
wandering  cells,  or  lymph,  or  colorless  blood,  corpus- 
cles. Other  investigators  are  of  the  opinion  that  the 
process  is  one  of  contiguous  infection,  without  there 
being  necessarily  a  migration  of  the  epithelial  cells 
out  of  the  acini ;  that  is  to  say,  the  subepithelial  cells 
of  the  membrana  propria  are  first  metamorphosed, 
then  those  of  the  outermost  layer  which  plays  the 
part  of  an  adventitia,  and,  finally,  those  of  the  peri- 
glandular infiltrate.  Still  another  view  is  that  the 
epithelial  masses  are  prolonged  into  and  infect  the 
cells  of  the  lymph  spaces,  which  may  be  wandering 
elements  or  the  offspring  of  the  connective  tissue  cor- 
puscles. 

The  latest  doctrine  in  regard  to  the  development  of 
carcinoma,  its  local  extension,  and  the  alveolar  group- 
ing of  the  cells,  is  that  of  Creighton,*  who  maintains  its 
epithelial  origin  and  the  infection  of  the  cells  of  the 
stroma,  as  do  the  authorities  cited  in  the  preceding 
paragraph,  but  with  these  differences :  He  endeavors 
to  show,  first,  that  the  post-climacteric  mamma  does 
not  contain  many  normal  acini,  but  that  the  epithelial 
cells  which  were  once  contained  within  the  acini  posi- 
tively infiltrate  the  connective  in  the  fonn  of  rows, 
and  lie  in  contact  with  its  corpuscles,  which  latter 
are  infected ;  and,  secondly,  that  the  alveolar  struc- 

'  Journal  of  Anatomy  and  Physiology,  Oct.,  1879,  pp.  29-49. 


EVOLUTION.  17 

ture  is  due  to  the  cells  pressing  aside  the  parallel 
bundles  of  the  connective  in  which  they  lie.  In 
accordance  with  this  remarkable  view,  the  cells  do 
not  wander  out  of  the  enlarged  acini  into  the  inter- 
stices of  the  connective,  nor  do  they  grow  as  solid 
plugs  into  the  lymph  spaces ;  but  they  are  found  pri- 
marily in  the  alveoli  as  a  result  of  a  partial  breaking 
down  of  the  glandular  apparatus  of  an  obsolescent 
mamma. 

Althou2:h  the  fact  is  well  established  that  the 
proliferating  epithelium  does  grow  into  the  lymph 
spaces,  and  extends  as  solid  plugs  or  cylinders  into 
the  lymphatic  vessels,  the  more  modern  investigations 
of  Woodward,'  Waldeyer  and  Carmalt,''  and  Lang- 
hans,"  not  only  do  not  confom  the  opinion  of  Rind- 
fleisch  that  the  l}TQphatic  endothelium  participates  in 
the  production  of  the  epithelial  cells,  but  they  are 
directly  opposed  to  the  view  of  Koester  that  carci- 
noma originates  through  metaplasia  of  that  structure. 
Thus  they  show,  by  staining  with  silver,  that,  al- 
though the  mammary  lymphatics  were  filled  Avith 
masses  of  epithelium,  their  endothelial  lining  re- 
mained unchanged ;  and  I  myself  can  confiiTu  these 
observations  from  recent  numerous  examinations  of 
sections  of  a  scirrhous  cancer  of  an  outlying  lobule  of 
the  breast  of  a  woman  of  fifty-two  years,  which  had 
attained  the  size  of  a  filbert  in  five  months.  Many 
of  the  alveoli,  when  freed  of  their  contents,  were 
seen  to  be  lined  with  endothelial  cells  which  did  not 
evince  the  slightest  indication  of  irritation,  much  less 

'  The  Minute  Anatomy  of  livo  Cases  of  Cancer^  War  Department,  Washing- 
ton, 1872. 

*  VircliovS's  Arcliiv,  Bd.  Iv,  pp.  145  and  4S5. 

^Archil)  fur  Gynaekolocfic,  Ed.  viii,  p.  181,  and  plate  vi,  fig.  5. 


18  NEOPLASMS  OF  THE  MAMMARY  GLAND. 

of  proliferation,  while  others  were  devoid  of  endothe- 
lial investment.  The  former  were  evidently  dilated 
lymphatics,  and  the  latter  were  due  to  the  extension 
of  the  epithelial  plugs  into  the  interstices  of  the 
newly  formed  periacinous  connective  tissue. 

In  his  remarkable  and  highly  original  work  en- 
titled "  Contributions  to  the  Physiology  and  Pathol- 
ogy of  the  Breast  and  its  Lymphatic  Glands,"  Dr. 
Creighton  has  advanced  most  novel  and  heterodox 
views  in  regard  to  the  development  of  the  mamma 
and  the  histological  processes  concerned  in  the  gene- 
sis of  its  neoplasms,  which  are  entitled  to  the  most 
respectful  consideration,  and  which,  should  they  prove 
to  be  well  founded,  will  overthrow  the  assumptions 
of  previous  observers  on  these  points. 

The  generally  accepted  theory  of  the  development 
of  the  breast,  namely,  that  it  is  due  to  an  infolding 
of  the  epiblast  or  cuticular  layer  of  the  embryo,  is 
radically  opposed  by  Creighton,  who  teaches  that  it  is 
merely  a  modified  fat  gland  formed  in  the  mesoblas- 
tic  layer  of  the  embryo,  so  that  its  glandular  and  con- 
nective tissue  elements  are  histologically  equivalent. 
With  this  understanding,  he  attempts  to  show  that 
the  "  various  forms  of  tumor  correspond  to  the  vari- 
ous states  of  the  secreting  structure,  and  to  the  vari- 
ous degrees  of  the  secretoiy  force,  as  measured  on  the 
physiological  scale."  In  consequence  of  some  mor- 
bid influence  or  diseased  excitation,  the  gland  reacts 
by  following  the  slow  process  of  normal  evolution ; 
but,  as  the  evolution  or  unfolding  is  spurious,  it  is 
associated  with  the  formation  of  peculiar,  imperfect, 
crude,  or  waste  cellular  products,  which  are  derived 
from  the  epithelium,  and  accumulate  in  the  acini,  or 


EVOLUTION.  19 

leave  them  to  infiltrate  tlie  periacinous  tissue,  instead 
of  passing  out  of  the  mamma  by  the  lymphatics  to 
be  converted  into  lymphoid  cells  in  the  lymph  glands. 
Hence  he  ascribes  the  formation  of  morbid  growths 
to  vacuolation  and  metaplasia  of  the  secreting  cells, 
the  products  of  which  may  remain  in  situ  or  wander 
out  of  the  acini,  and  give  rise,  in  accordance  with  the 
stage  of  evolution  which  they  represent,  to  carcino- 
ma, sarcoma,  myxoma,  or  chondroma. 

"  Measured  on  the  physiological  scale,  the  cells  of 
carcinoma  belons;  to  the  intermediate  stasre  of  the 
breasts'  unfolding,  and  they  stand  for  a  haH-roused 
functional  stimulus,"  which  is  always  characterized 
by  a  feeble  secretory  force.  If  they  accmnulate 
within  the  acini,  they  produce  medullary  carcinoma, 
while  the  extraacinous  infiltration  of  the  interfasci- 
cular spaces  engenders  scirrhus. 

Myxoma  corresponds  to  that  condition  of  the 
secretins;  structure  and  to  that  des-ree  of  the  secret- 

O  CD 

ory  force  which  is  associated  with  the  j)i'o<iuction 
of  mucus,  so  that  "  the  physiological  type  is  that  of 
the  later  period  of  evolution  in  which  the  function 
comes  near  in  its  intensity  to  the  perfect  lactation." 

Corresponding  to  the  same  stage  of  evolution,  the 
cells  of  the  acini  become  elongated,  or  are  trans- 
formed into  spindle  cells,  and  leave  the  acini  to 
accumulate  in  the  periacinous  tissue  to  form  sarcoma. 
Should  some  of  the  same  transformed  epithelial  cells 
remain  in  the  acini,  the  structure  is  that  of  adeno- 
sarcoma;  so  that  Creighton  discards  altogether  the 
connective  tissue  origin  of  sarcoma,  and  holds  fast  to 
the  doctrine  that  the  cells  ar.e  nothinof  more  nor  less 
than  spindle-shaped  epithelial  cells. 


20  l^EOPLASMS  OF  THE  MAMMARY  GLAND. 

Chondroma  also  corresponds  to  tlie  same  degree 
of  excitation  tliat  affords  mucus,  and  is  a  cartilaginous 
transformation  of  myxomatous  tissue,  except  that,  in- 
stead of  there  being  a  fonnation  of  fluid,  a  hyaline 
intercellular  substance  is  produced. 

Inasmuch  as  Creighton  believes  that  the  stroma 
of  the  mammaiy  gland  is  the  same  in  its  histogenesis 
as  the  glandular  elements,  his  theory  that  tumors  of 
the  epithelial  type  and  of  the  connective  tissue  type 
are  merely  different  stages  in  the  same  series  of  de- 
velopmental changes  need  not  strike  us  with  aston- 
ishment ;  and  I  must  confess  that  his  views  were  so 
allurino;  that  I  have  devoted  no  little  time  durins:  the 
past  twelve  months  in  attempting  to  conlinn  his  state- 
ments, as  far  at  least  as  sarcoma  is  concerned,  but 
with  entirely  negative  results.  In  point  of  fact,  Dr. 
Creighton's  description  of  the  appearances  presented 
by  a  scirrhous  carcinoma  of  the  male  mamma,  re- 
moved by  Mr.  Wagstaffe,'  tends  to  throw  discredit  on 
his  own  positive  conclusions  in  regard  to  the  extra- 
acinous  infiltration  of  large,  nuclear  cells  being  the 
distinguishing  feature  of  scirrhus.  In  his  report  he 
states  that  the  acini  were  irresrular  in  form  and 
enlarged ;  that  "  their  epithelium  remained  in  situ, 
as  in  a  healthy  acinous  gland ; "  and  that  the  acini 
were  surrounded  by  a  periacinous  growth  of  fibrous 
tissue. 

These  opposed  and  perplexing  views  as  to  the 
histogenesis  of  morbid  growths  of  the  mamma  can 
scarcely  excite  wonder,  when  it  is  remembered  that 
there  is  still  some  diversity  of  opinion  as  to  what 
constitutes  the  connective  tissue  corpuscle ;  that  we 

'  Trans.  PatJi.  Soc.  London,  vol.  xxvii,  p.'  235. 


EVOLUTION.  21 

are  unsettled  as  to  tlie  origin  of  the  broods  of  young 
cells  wliich  are  so  extensively  met  with  in  carcinoma, 
sarcoma,  and  rapidly  growing  fibroma ;  that  it  is  im- 
possible by  any  known  methods  of  treatment  to  dis- 
tinguish between  these  cells  and  the  first  cells  which 
afterward  become  carcinomatous  epithelium;  and, 
finally,  that  we  are  by  no  means  certain  in  regard  to 
the  development  of  the  mamma. 

For  my  own  part,  and  my  views  are  amplified  in 
the  chapters  on  the  different  neoplasms,  I  regard  the 
lacteal  glands  as  the  starting-point  of  adenoma  and 
carcinoma,  and  the  connective  as  the  matricular  tissue 
of  the  histoid  or  simple  neoplasms.  I  by  no  means, 
however,  restrict  tumor  formation  to  the  continuous 
multiplication  of  the  indigenous  cells  of  the  mamma ; 
but  regard  the  wandering  cells  as  contributing  their 
share  in  the  production  of  the  indifferent  cells  out  of 
which  the  connective  tissue  growths  originate,  and 
out  of  which  the  newly  formed  stroma  of  carcinoma 
is  produced.  As  will  be  pointed  out  in  the  chapter 
on  the  latter  affection,  I  believe  that  the  continuous 
proliferation  and  transplantation  of  the  epithelium 
are  quite  sufiicient  to  account  for  all  the  changes  met 
with  in  the  development  and  extension  of  carcinoma, 
without  invoking  the  mysterious  spermatic  influence 
of  Mr.  Simon,  the  action  de  presence  of  the  French,  or 
the  epithelial  infection  of  the  German,  school,  through 
which  the  epithelium  is  assumed  to  have  acquired  the 
property  of  transforming  all  cells  with  which  it  comes 
in  contact  into  a  likeness  to  itself. 

Having  once  started,  neoplasms  increase  by  central 
growth,  or  by  the  progressive  multiplication  of  their 
own  cells,  as  occurs  in  the  connective  tissue  series  and 


22  NEOPLASMS  OF  THE  MAMMARY  GLAND. 

in  adenoma,  or  by  peripheral  extension  along  the 
lymphatics  or  the  perivascular  sheaths  of  the  blood- 
vessels, as  is  witnessed  in  carcinoma.  In  the  first 
mode  the  tumor  remains  circumscribed  and  encap- 
suled,  while,  in  the  second,  it  infiltrates  and  destroys 
the  adjacent  tissues,  and  is  not  inclosed  by  a  fibrous 
membrane.  Sarcoma,  however,  may  extend  along 
the  bloodvessels  and  invade  the  adjoining  tissues, 
without  its  capsule  being  necessarily  destroyed. 
Hence  during  their  further  gro^vth  and  extension 
carcinoma  and  sarcoma  exhibit  malignant  attributes, 
as  evinced,  in  the  former,  by  the  continuous  growth 
of  the  cells  into  the  coverings  of  the  mamma  and  the 
subjacent  structures,  and  by  their  transportation  to  the 
associated  lymphatic  glands  and  the  viscera,  where 
they  proliferate  and  supplant  the  natural  tissues; 
and,  in  the  latter,  by  the  same  phenomena,  with  the 
exception  of  the  conversion  of  the  lymphatic  glands 
into  secondary  growths.  As  these  features  mil  be 
fully  discussed  in  the  chapters  on  the  several  growths, 
they  need  not  detain  us  here. 

Although  the  tendency  of  neoplasms  is  to  persist 
unchanged  and  increase,  yet  a  time  comes  when  they 
are  subject  to  the  same  diseases  as  are  the  normal 
tissues.  Thus  they  may  inflame,  suppurate,  ulcerate, 
and  die ;  and  they  are  liable  to  various  degenerations 
and  infiltrations,  as  the  fatty,  caseous,  mucoid,  telan- 
giectatic, colloid,  pigmentary,  and  calcareous,  which 
give  rise  to  certain  subdivisions,  and  to  which  I  shall 
again  have  occasion  to  refer  when  discussing  the  in- 
dividual gro^vths. 

From  a  histological  as  well  as  a  practical  point  of 
view,  it  is  a  matter  of  great  interest  to  determine 


TRAFSFORMATIOK  23 

whether  a  mammary  neoplasm  ever  so  changes  its 
original  type  that  one  which  has  remained  innocent 
for  a  series  of  years  finally  degenerates  into  one  of  a 
malignant  nature,  or  one  which  possesses  the  struc- 
ture of  a  carcinoma  or  a  sarcoma. 

Among  French  writers/  Verneuil,  Houel,  and  De- 
sprez  adduce  cases  to  prove  the  transformation  of  so- 
called  adenoid  tumors  into  carcinoma,  while  Ranvier, 
Broca,  Richet,''  and  Richelot  *  deny  such  an  occur- 
rence. Billroth  *  has  described  and  delineated  the 
development  of  carcinoma  from  an  adenoid  sarcoma, 
and  both  he  and  Klebs '  state  that  fibrous  tumors  are 
very  frequently  the  starting  point  of  cancer.  Sir 
James  Paget '  has  quite  recently  pointed  out  that  not 
only  hard  mammary  glandular  tumors,  but  certain 
ill-defined  and  tough,  rather  than  hard,  indurations 
may  become  carcinomatous.  The  tendency  of  true 
adenoma  to  pass  into  carcinoma  is  so  well  established 
that  it  need  not  be  dwelt  upon ;  and  it  need  scarcely 
be  said  that  the  epithelium  of  the  acini  of  these,  and 
of  the  so-called  adenoid  growths,  as  well  as  of  the 
lobular  indui^ations,  is  the  point  of  departure  of  the 
transformation. 

Billroth,"  Labbe  and  Coyne,*  and  Duplay '  are  of 
the  opinion  that  the  metamorphosis  of  fibroma  into 
sarcoma  is  so  frequent  that  primary  sarcoma  of  the 

^  Bull,  de  la  Soc.  Anaf.,  t.  xliv,  p.  285  e(  seq. 

^Le  Fradicien,  No.  14,  1879,  p.  163. 

^  Des  Tumeurs  KyRtiquea  de  la  Mamelle,  1878,  p.  102. 

*  Virchoid's  ArcJiiv,  Bd.  xviil,  p.  78,  and  Surgical  Pathology,  edited  by  Hack- 
ley,  p.  647. 

'Op.  «7.,p.  1207. 

*  St.  Bartholomew'' s  Hospital  Reports,  vol.  xiv,  p.  65. 
'  Chir.  Llinik,  Wien,  1871-'76,  p.  261. 

8  Op.  cit.,  pp.  269,  283,  and  363. 
'  Op.  dt.,  p.  628, 


24:  NEOPLASMS  OF  THE  MAMMARY  GLAND. 

mamma  is  very  rare  ;  and  this  view  would  seem  to  be 
verified  by  tlie  fact  that  a  tumor  whicli  has  remained 
of  the  volume  of  a  walnut  for  fifteen  years  may  in 
three  months  rapidly  increase  to  the  size  of  a  double 
fist;'  or  attain  a  circumference  of  twenty-six  inches 
and  a  weight  of  seven  pounds  in  six  months,  after 
having  existed,  not  larger  than  an  egg,  for  a  year  and 
a  half.*  In  such  cases  it  would  appear  as  if  a  fibroma 
had  been  converted  into  a  sarcoma  through  multipli- 
cation of  its  cells  and  increased  vascularization,  al- 
though the  opponents  of  a  change  of  type  might  urge 
that  a  sarcoma  may  remain  latent  for  many  years, 
when,  without  obvious  cause,  it  begins  to  grow  rapid- 
ly through  proliferation  of  its  cells,  and  a  proportion- 
ate decrease  of  its  fibrous  intercellular  substance. 

Tumors  of  the  connective  tissue  and  of  the  epithe- 
lial series  may  coexist  in  one  or  both  mammae.  Thus, 
Richet '  records  an  example  of  two  fibrous  growths, 
of  twenty-two  years'  duration,  in  the  lower  segment, 
and  a  recent  carcinoma  in  the  upper  segment  of  the 
same  gland.  Paget*  has  observed  a  similar  occur- 
rence; and  Walcleyer*  met  with  a  carcinoma  and 
eight  fibromata  in  one  breast.  Langhans "  reports  an 
adenoma,  of  nine  years'  growth,  and  a  carcinoma,  of 
six  months'  duration,  side  by  side.  De  Morgan '  and 
Billroth'  have  each  seen  a  cystic  sarcoma  in  one 
breast,  and  a  scirrhous  carcinoma  in  its  fellow. 

'  Marignac,  Bull,  de  la  Soc.  Anal.,  t.  lii,  p.  428. 

2  Marchand,  Gazette  des  Ilopitaux,  No.  51,  1869,  p.  196. 

^  Loc.  cif.,  ante. 

*  Op.  cit.,  p.  565. 

^  Virchow''s  Archiv,  Bd.  Iv,  p.  124. 

«  Ibid.,  BJ.  Iviii,  p.  147. 

'  Trans.  Path.  Soc.  Lond.,  vol.  xix,  p.  394. 

8  CUr.  Klinik,  Wien,  18n-'76,  p.  263. 


CHAPTEE    III. 

THE  ETIOLOGY  OF  NEOPLASMS   OF  THE  MAMMA. 

The  causes  wliicli  determine  tlie  development  of 
the  new  formations  of  the  mammary  gland  are  ob- 
scure ;  but  tKey  demand  sometliing  more  than  a  pass- 
ing notice,  since  they  have  been,  and  are  still,  relied 
upon  as  furnishing  data  for  the  differential  diagnosis 
of  the  non-carcinomatous  and  the  carcinomatous  neo- 
plasms. 

The  traditional  opinions  in  regard  to  the  antece- 
dents, precursors,  or  conditions  which  favor  the  oc- 
currence of  the  non-carcinomatous  growths,  are  that 
they  are  influenced  by  traumatism,  comparative  youth, 
celibacy,  sterility,  disordered  menstruation,  and  a  ner- 
vous, excitable,  or  hysterical  disposition;  or,  when 
they  originate  in  married  women,  that  they  appear 
most  frequently  during  pregnancy  and  lactation. 
The  development  of  carcinoma,  on  the  other  hand,  is 
presumed  to  be  influenced  by  the  married  state,  by 
prolificness,  and  by  the  cessation  of  the  menstrual 
function. 

That  injury  is  capable  of  setting  up  a  sufficient 
amount  of  irritation  of  the  component  tissues  of  the 
mamma  to  eventuate  in  the  formation  of  the  new 
growths  cannot  be  doubted ;  but  that  it  is  a  factor 
peculiar  to  the  non-carcinomatous  group  is  not  shown 
by  an  analysis  of  the  cases  upon  which  this  mono- 


26  NEOPLASMS  OF  TEE  MAMMARY  GLAND. 

grapli  is  based,  as  the  simple  neoplasms  were  ascriba- 
ble  to  trauma  in  11*94  per  cent,  of  all  instances,  wMle 
11'70  per  cent,  of  tlie  carcinomata  could  be  traced  to 
the  same  cause. 

Of  the  non-carcinomatous  subjects  in  whom  the 
social  condition  and  the  activity  of  the  sexual  ajDpara- 
tus  are  noted,  61  per  cent,  were,  or  had  been,  married, 
and  in  only  15*55  per  cent,  of  these  did  the  growth 
develop  during  pregnancy  or  lactation ;  86  per  cent, 
had  borne  children ;  93  per  cent,  were  menstiniating, 
and  6  per  cent,  of  these  performed  that  function  ir- 
regularly ;  while  only  3  per  cent,  were  hysterical.  Of 
the  carcinomatous  patients,  88*22  per  cent,  were,  or 
had  been, married ;  83  per  cent,  were  fruitful;  and  61 
per  cent,  v^^ere  regular  as  regards  the  catamenial  func- 
tion when  the  tumor  was  first  observed.  In  5  per 
cent,  of  this  class  the  growth  developed  during  preg- 
nancy or  lactation.  In  only  40  per  cent,  of  the  non- 
carcinomatous  neoplasms  were  the  patients  compara- 
tively young,  that  is  to  say,  they  had  not  attained  the 
age  of  thirty. 

These  facts  show  conclusively  that,  contrary  to 
the  generally  received  views,  the  non-carcinomatous 
neoplasms  are  most  common,  after  the  thirtieth  year, 
in  married  and  prolific  females,  who  are  not  the  sub- 
jects of  disordered  menstruation  or  of  a  nervous  habit ; 
and  that  their  development  is  attributable  to  trauma 
in  only  one  example  out  of  every  eight  and  a  half,  and 
to  pregnancy  or  lactation  in  less  than  one  instance 
out  of  every  seven.  A  comparison  of  the  percentages 
will,  moreover,  demonstrate  that  an  almost  equal 
number  in  each  class  are  prolific,  and  that  the  apparent 
differences  in  the  menstrual  function  and  in  the  social 


ETIOLOGY.  27 

condition  may  be  explained  by  tlie  fact  that  fewer 
women,  tlie  subjects  of  the  non-carcinomatous  neo- 
plasms, are  to  be  expected  to  be  married,  in  conse- 
quence of  their  comparatively  early  age,  while,  for 
the  same  reason,  more  are  menstruating.  Hence  these 
data  are  not  favorable  to  the  current  view  that  the 
development  of  mammary  gro^vths  is  influenced  by 
the  state  of  the  organs  of  reproduction,  although  at 
first  sight  pregnancy  and  lactation  Avould  seem  to 
bring  about  such  changes  in  the  mamma,  such  as  in- 
creased supply  of  blood  and  activity  of  cell  produc- 
tion, as  to  predispose  it  to  tumor  formation ;  but  a 
little  closer  examination  will  show  that  the  propor- 
tions existing  between  sterile  and  fruitful,  and  single 
and  maiTied  women,  affected  with  mammary  growths, 
coiTespond  to  the  proportions  which  exist  between 
females  who  are  free  from  tumors. 

Among  the  causes  which  do  really  appear  to  in- 
fluence the  development  of  carcinoma,  great  weight 
is  attached  to  hereditary  transmission  by  Paget,' 
which  he  reo:ards  as  evidence  of  the  constitutional 
origin  of  that  affection,  just  as  he  looks  upon  local 
reproduction  and  the  formation  of  metastatic  tumors 
in  the  viscera  as  signs  of  an  original  cancerous  taint. 
While  much  may  be  said  in  favor  of  this  view,  I  must 
state  explicitly  that  I  am  no  believer  in  the  constitu- 
tional derivation  of  carcinoma,  but  regard  the  inher- 
itance as  merely  the  expression  of  the  transmission  of 
a  predisposition  to  a  local  disease,  just  as  is  seen  in 

'  Trans.  Fath.  Soc.  London,  vol.  xxv,  1874:  Discussion  on  Cancer.  This 
extremely  interesting  discussion  embraces  the  recent  views  of  many  of  the  most 
distinguished  English  pathologists.  In  it,  Sir  William  Gull,  Arnott,  Hutchinson, 
Payne,  Moxon,  and  others  maintain  the  strictly  local  origin  of  carcinoma,  in  op- 
position to  Sir  James  Paget,  who  looks  upon  it  as  a  disease  of  the  blood. 


28  NEOPLASMS  OF  TEE  MAMMARY  GLAND. 

the  hereditariness  of  lipoma,  chondroma,  or  sebaceous 
cysts  in  other  organs  or  tissues,  which  no  one  regards 
as  beins;  the  local  manifestation  of  a  constitutional  or 
a  blood  vice.  Recurrence  after  removal,  the  contami- 
nation of  the  associated  lymphatic  glands,  and  the 
development  of  precisely  similar  growths  in  the  vis- 
cera, are  surely  explicable  on  the  ground  that  the 
primary  tumor  acts  as  a  focus  of  infection  of  neigh- 
boring and  distant  parts,  without  invoking  the  theoiy 
of  a  constitutional  taint.  Be  this  as  it  may,  the  influ- 
ence of  heredity  is  not  witnessed  in  the  non-carci- 
nomatous  tumors,  while  it  is  seen  in  one  case  out  of 
every  nine  of  the  carcinomata,  and  therefore  serves 
as  a  point  of  distinction  between  the  simple  and  can- 
cerous neoplasms. 

Among  the  precursors  of  carcinoma,  eczema  and 
psoriasis  of  the  nipple  and  areola  have  recently  at- 
tracted considerable  attention,  as  was  first  pointed 
out  by  Sir  James  Paget ; '  and  the  connection  between 
these  affections  has  been  observed  by  Butlin,  Morris, 
Lawson,  Busch,  and  other  surgeons,  including  two 
cases  under  my  own  care,  one  of  which  I  made  the 
subject  of  a  report  to  the  Pathological  Society  of 
Philadelphia." 

The  cases  of  Paget,  fifteen  in  number,  occurred  in 
women  varying  in  age  from  forty  to  sixty  years,  in 
the  majority  of  which  the  nipple  or  areola  was  the 
seat  of  an  intensely  red,  very  finely  granular,  raw  sur- 
face, discharging  a  copious,  clear,  yellowish,  viscid 
fluid,  and  attended  with  a  tingling,  itching,  or  burn- 
ing sensation.     In  some  the  eruption  presented  the 

'  St.  Bartholomeiv'' s  Hosp.  Heps.,  vol.  x,  p.  87. 
«  Fhiia.  Med.  Times,  July  5,  IS'79,  p.  486. 


ETIOLOGY.  29 

ordinary  characters  of  chronic  eczema,  while  in  others 
it  was  dry,  like  psoriasis.  With  the  view  of  deter- 
minino;  whether  these  affections  could  be  reo-arded  in 
the  light  of  cause  and  effect,  Mr.  Butlin  '  examined 
two  breasts,  the  nipples  of  which  were  the  seat  of 
chronic  eczema,  and  found  that  the  ducts  were  wide- 
ly dilated,  and  contained  frequently  large  masses  of 
squamous  epithelium,  and  that  the  connective  tissue 
was  infiltrated  with  small  cells.  In  an  induration 
which  existed  in  one  of  the  breasts,  the  acini  were 
also  found  to  be  enlarged  and  filled  with  epithelium. 
Although  there  was  no  carcinoma  in  either  case,  these 
appearances  indicated  the  commencement  of  morbid 
processes  which  lead  to  the  development  of  that  af- 
fection. Continuing  his  investigations,  Mr.  Butlin," 
a  year  subsequently,  described  the  minute  anatomy 
of  two  instances  of  scirrhus  of  the  mamma  which 
was  preceded  by  eczema.  In  both,  the  tissues  be- 
tween the  neoplasm  and  the  areola  were  somewhat 
indurated,  and  the  appearances  were  the  same  as 
they  were  in  the  former  cases,  with  the  addition, 
in  one,  of  cell-nests  in  the  thickened  portions  of  the 
nipple  and  areola,  and  of  "  much  greater  enlargement 
of  the  acini  and  ducts  in  the  centre  of  the  carcinoma 
than  in  the  previous  cases,  so  that  they  had  become 
confluent,  and  their  contents  had  made  their  way  into 
the  surrounding  tissues." 

Recent  investigations  appear  to  point  to  some- 
thing more  than  an  ordinary  eczematous  condition, 
since  Dr.  Thin '  concludes,  from  a  study  of  sections  de- 
rived from  four  specimens,  that  the  disease  is  super- 

'  Med.  CJiir.  Trans.,  vol.  lis,  p.  107.  ^  Ibid.,  vol.  Ix,  p.  153. 

3  London  Lancet,  vol.  ii,  1S79,  p.  8Y4,  and  vol.  i,  18S0,  p,  92. 


80  NEOPLASMS  OF  THE  MAMMARY  GLAND. 

fici?,!  epithelioma  of  the  moutlis  of  the  lacteal  ducts, 
from  which  it  extends  along  the  smaller  ducts  into 
the  substance  of  the  mamma,  and  finally  infiltrates 
the  connective  tissue  by  breaking  through  the  mem- 
brana  propria,  thereby  giving  rise  to  the  tubular  or 
duct  form  of  carcinoma,  while  the  changes  in  the 
tissues  of  the  nipple  and  the  surrounding  skin  are 
solely  of  an  irritative  nature. 

While  it  may  be  tiTie  that  the  primary  lesion  is 
sometimes  carcinoma  of  the  ducts  contained  within 
the  mamilla,  I  am  of  the  opinion  that  cancer  may 
result  from  ordinary  eczema  or  psoriasis  of  the  nipple, 
just  as  epithelioma  of  the  tongue  may  follow  ichthy- 
osis, or  hyperplasia  of  the  epithelium,  of  that  organ. 
From  the  clinical  side,  the  long  duration  of  the  erup- 
tion before  the  appearance  of  the  carcinoma  in  the 
gland,  and  its  curability,  as  Busch '  has  pointed  out, 
and  as  I  myself  have  witnessed  in  one  case,  by  the 
application  of  a  four-per-cent.  solution  of  soda,  or  as 
Chambers '  has  shown,  by  a  lotion  containing  equal 
parts  of  glycerine  and  laudanum,  without  the  develop- 
ment of  cancer,  surely  point  to  a  simple  local  con- 
dition. From  the  anatomical  side  much  may  be  said 
in  favor  of  the  same  view.  Thus,  it  is  not  quite  clear 
that  Thin  really  met  Avith  carcinoma  in  all  of  his  ex- 
aminations, as  he  says  that  the  tumors  which  he  in- 
spected were  the  same  as  those  which  are  described  as 
adenoid  or  adenomata  by  English  and  some  German 
writers,  and  by  Labbe  and  Coyne  as  epithelioma  in- 
tracanaliculaire,  which  they  distinctly  state  is  synony- 
mous with   the   true   adenoma   of   certain   authors.' 

'  LangenhecTi's  Arcliiv,  Bd.  xxi,  p.  687.         ^  Lancet,  vol.  ii,  1879,  p.  743. 
8  Op.  ciL,  p.  366. 


ETIOLOGY,  31 

Apart  from  tliese  considerations,  neoplasms  otlier 
than  carcinoma  may  be  preceded  by  simple  eczema 
or  psoriasis.  Thus,  in  the  patient  from  whom  figs. 
9  and  12  were  derived,  a  spindle-celled  sarcoma,  of 
seven  years'  duration,  had  been  preceded  by  psoriasis 
of  the  nipple  ever  since  she  could  remember;  and 
she  frequently  picked  off  crusts  which  she  said  looked 
like  pearl  buttons.  In  a  case  of  true  adenoma,  re- 
corded by  Labbe  and  Coyne,'  the  woman  had  been 
in  the  habit,  for  nearly  thirty  years,  of  removing 
small  scales  from  the  orifices  of  the  ducts,  which  was 
followed  by  the  escape  of  a  lactescent  fluid. 

These  data,  which  throw  new  and  unexpected 
light  upon  this  point,  demonstrate  that  eczema  or 
psoriasis  of  the  nipple,  or  Paget's  disease,  to  use  the 
term  suggested  by  Mr.  Erichsen,  may  antedate  both 
divisions  of  neoplasms.  Those  affections  were  met 
with  in  2  out  of  138  non-carcinomatous  growths,  or  in 
the  ratio  of  1*44  per  cent.,  while  they  were  the  cause 
of  7  out  of  675  cases  of  cancer,  or  in  the  proportion 
of  1*03  per  cent.,  as  will  again  be  pointed  out  in  the 
chapter  on  carcinoma. 

Another  assumed  predisposing  cause  of  carcinoma 
is  puerperal  mastitis  resulting  in  chronic,  circum- 
scribed indurations,  which  are  composed  of  glandu- 
lar structure,  surrounded  by  densely  hard  or  cicatri- 
cial connective  tissue.  Hence  these  lumps  do  not 
differ  from  the  normal  breast  during  senile  involution, 
and  it  is  quite  natural  that,  during  a  subsequent  lac- 
tation, or  under  the  influence  of  the  period  of  life 
when  carcinoma  may  be  looked  for,  the  included  lac- 
teal glands  should  not  react  physiologically,  but  grow 

»  Op.  ciL,  p.  356. 


32  NEOPLASMS  OF  TEE  MAMMARY  GLAND. 

atj^pically  and  lay  tlie  foundation  of  cancer.  Of  365 
women  wlio  liad  borne  children  tliere  was  antecedent 
mastitis  in  71,  but  in  only  30  of  these  did  an  indura- 
tion remain  from  wliich  carcinoma  originated.  Hence 
tlie  disease  appears  to  be  connected  witli  this  condi- 
tion in  8*2 1  per  cent,  of  all  cases;  but  it  is  interesting 
to  note  that  these  lumps  remain  quiescent  for  a  pe- 
riod which  varies  from  four  to  twenty-eight  years,  or 
a  little  more  than  fourteen  years  on  an  average ;  or, 
in  other  Avords,  until  the  age  arrives  which  is  most 
favorable  to  the  development  of  the  new  growth. 
In  one  of  my  own  cases  the  interval  between  the 
appearance  of  the  tumor  and  the  induration  left  by 
suppurative  mastitis  was  twenty-six  years,  the  patient 
having  been  twenty  years  old  at  the  date  of  the  in- 
flammation, and  forty-six  at  the  date  of  the  appear- 
ance of  the  carcinoma;  while  in  one  recorded  by 
Winiwarter  the  interval  was  twenty-eight  years.  The 
non-carcinomatous  grov.i;hs  may  also  start  from  simi- 
lar lumps,  as  happened  in  1*44  per  cent,  of  all  cases, 
the  proportion  being,  however,  far  less  than  is  vni- 
nessed  in  the  preceding  group. 

On  reviewing  the  predisposing  and  exciting  causes 
of  mammary  neoj)lasms  it  will  be  seen  that,  with  the 
single  exception  of  hereditability,  not  one  is  of  much 
value  in  tracing  the  genesis  of,  or  in  aiding  in  the 
determination  of  the  diagnosis  between,  the  simple 
and  the  carcinomatous.  Hence  I  am  of  the  opinion 
that  their  development  is  connected  with  the  changed 
proportions  of  the  component  tissues  of  the  breast  at 
different  penods  of  life,  and  that  the  condition  of 
the  tissues  is,  as  a  rule,  indicated  by  the  age  of  the 
patient. 


ETIOLOGY.  33 

Tlie  non-carcinomatous  growths  occur,  on  an  aver- 
age, at  tlie  t]iiii:y -third  year;  only  30*37  i)er  cent,  de- 
velop after  the  age  of  forty,  or  when. the  physiological 
life  of  the  mamma  is  beginning  to  be  impaired ; ' 
15*55  per  cent,  appear  before  the  twentieth  year;  and 
5*18  j)er  cent,  are  met  mth  before  the  establishment 
of  menstruation.  Previously  to  the  age  of  forty,  or 
during  the  period  of  the  structural  j)erfection  of  the 
gland,  or  when  the  proportion  existing  between  the 
ej)ithelial  and  connective  tissue  constituents  is  nonnal, 
fibromata  and  sarcomata  are  the  most  common  of  the 
neoplasms ;  or,  if  the  epithelium  be  disturbed  or  ex- 
cited, it  reacts  more  in  accordance  with  its  physiologi- 
cal evolution,  and  adenoma  results.  When  carcinoma 
occurs  between  the  third  and  fourth  decades,  it  signi- 
fies that  the  breast  is  prematurely  old." 

The  carcinomatous  tumors  develop,  on  an  average, 
at  the  forty-eighth  year;  77*26  per  cent,  appear  after 
the  age  of  forty ;  and  they  are  never  met  with  before 
the  twentieth  year.  With  advancing  age  the  con- 
nective tissue  stroma  of  the  mamma  preponderates, 
and,  as  it  contracts,  the  lacteal  glands,  for  the  most 
part,  atrophy  and  disappear  through  absorption  of 
their  cells  which  have  undergone  fatty  degeneration. 
If,  however,  instead  of  passing  through  these  normal 
obsolescent  processes,  the  contracting  fibrous  tissue 
produces  irritative  changes  in  the  epithelial  cells,  the 

'  Although  it  is,  if  I  do  not  mistake,  customary  to  regard  the  mamma  as 
being  perfect  up  to  the  age  of  forty-five,  when,  on  an  average,  the  catamenial 
function  ceases,  I  am  of  the  opinion  that  the  secreting  structure  begins  to  waste 
at  forty,  and  that  the  stage  of  decline  occurs  several  years  earlier  in  feeble 
women. 

"  Atrophy  of  the  lacteal  glands  now  and  then  shows  itself  in  early  life 
through  their  failure  to  develop  during  pregnancy,  and  through  the  absence  of 
milic  after  parturition. 
3 


34 


NEOPLASMS  OF  TEE  MAMMARY  GLAND. 


latter  increase  actively  and  abnonnally,  and  lay  the 
foundation  of  tumors  wliicli  are  carcinomatous  in 
98*80  per  cent,  of  all  instances.  At  this  same  period 
the  fatty  constituents  of  the  connective  are  exces- 
sive, and,  as  Virchow  has  shown  the  parallelism 
between  adipose  and  mucous  tissues,  if  the  fatty  ele- 
ments react  instead  of  the  epithelial,  they  revert 
to  their  original  mucoid  state,  and  a  myxoma  is  de- 
veloped. 

It  will  thus  be  seen  that  age,  or  rather  the  ana- 
tomical arrangement  of  the  stromal  and  epithelial 
constituents  as  indicated  by  the  age,  does  exercise  a 
most  marked  influence  upon  the  kind  of  neoplasm  to 
which  the  mamma  is  most  liable.  Among  themselves 
they  manifest,  however,  some  decided  variations,  as  is 
indicated  by  the  subjoined  tabular  statement  of  777 
cases  in  which  the  as-e  is  noted.  For  convenience  of 
reference  I  have  separated  their  occurrence  at  the  dif- 
ferent decades. 


Fibroma. 

Sarcoma. 

Myxoma. 

Adenoma. 

Carcinoma. 

Tears. 
Between  10  and  20 

Per  ct. 
11  or  22 
18  •'  36 
11  "  22 
7  "  14 
3  "     6 


Per  ct. 

8  or  13-33 

10  "  16-16 

23  "  38-33 

13  "  21-66 

4  "     6-66 

2  "     3  33 

Per  ct. 
1  or  14-29 

Per  ct. 
2  or  11-11 

4  "  22  22 
6  "  33-33 

5  "  27-77 
1  "     5-55 

Per  ct. 

"       20    "   30 
"        30    "   40 

18  or    2-80 
128  "  19-93 

"        40    "    50 
"        50    "    60 
"        60    "    70 

4  "  57-14 
2  "  28-57 

245  "  38-16 

165  "  25-70 

78  "  12-14 

"        70   "   80 

8  "     1-24 

Cases 

50 

60 

7 

18 

642 

Arranging  the  cases  in  accordance  with  the  func- 
tional activity  and  physiological  life  of  the  mamma,  a 
further  analysis  shows  that  there  appeared 


ETIOLOGY, 


35 


Fibroma. 

Sarcoma. 

Myxoma. 

Adenoma. 

Carcinoma. 

During  the  devel- 
opmental period. 

During  the  period 
of  greatest  ac- 
tivity   

During  the  period 
of  functional  de- 
cline   

Per  ct. 

6  or  12 

34  "  68 
10  "  20 

Per  ct. 
1  or    1-16 

40  "  66-66 

19  "  31-66 

Per  ct. 

Per  ct. 

Per  ct. 

1  or  14-29 
6  "  85-71 

12  or  66-66 
6  "  33-33 

146  or  22-74 
496  "  77-26 

50 

60 

7 

18 

642 

From  these  facts  it  is  evident  that  the  only  tumors 
that  develop  before  the  sixteenth  year  are  fibromata 
and  sarcomata,  and  that  the  chances  are  six  to  one  in 
favor  of  the  former.  It  is  further  quite  clear  that 
between  the  sixteenth  and  fortieth  years  they  are 
most  common  in  the  following  order:  fibroma,  sar- 
coma, adenoma,  carcinoma,  and  myxoma ;  and  that 
after  the  age  of  forty  the  order  is  reversed,  being 
myxoma,  carcinoma,  adenoma,  sarcoma,  and  fibroma. 
In  other  words,  structural  perfection  of  the  mamma 
renders  it  most  obnoxious  to  fibroma,  sarcoma,  and 
adenoma,  while  atrophy  or  decay  predisposes  it  to 
myxoma  and  carcinoma. 


CHAPTER lY. 

THE  ASATOMT  OF  TEE  CONNECTIVE  TISSUE  NEOPLASMS. 

The  connective  tissue  neoplasms  possess  certain 
features  in  conmion  which  I  shall  consider,  with  the 
view  of  avoiding  needless  repetition,  before  discuss- 
ing the  individual  growths  of  this  series.  Apart 
from  the  facts  that  they  are  usually  round  or  ovoid, 
bossed,  lobulated,  or  nodular  on  their  surface,  and  in- 
vested by  a  fibrous  capsule  which  separates  them 
from  the  remainder  of  the  gland,  but  vA\\i  the  latter 
of  which  they  are  frequently  more  or  less  closely  con- 
nected, their  coarse  appearance,  on  section,  indicates 
that  they  may  be  solid,  cystic,  or  vegetating.  Of  the 
120  cases  that  I  have  studied,  60,  or  50  per  cent.,  were 
solid;  7,  or  5*83  per  cent.,  were  cystic;  and  53,  or 
44*16  per  cent.,  were  vegetating,  or  proliferous. 
Ajnong  themselves,  however,  they  evince  striking 
differences  in  their  macroscopic  features,  since  60  per 
cent,  of  the  fibromata  are  solid,  and  40  per  cent,  are 
vegetating;  41*6  per  cent,  of  the  sarcomata  are  solid, 
11'6  per  cent,  cystic,  and  46*6  per  cent,  vegetating; 
while  50  per  cent,  of  the  myxomata  are  solid,  and  50 
per  cent,  are  vegetating.  The  cut  surfaces  of  the 
solid  tumors  are  smooth  and  unbroken.  The  cystic 
and  vegetating  forms,  on  the  other  hand,  are  pervaded 
by  fissui'es,   fluid   cysts,    or   cysts    containing    solid 


ANATOMY.  37 

growths ;  but  as  the  cysts,  whether  they  be  barren, 
fluid,  or  solid,  arise  primarily  in  the  same  way,  and 
as  the  clinical  features  of  the  cystic  and  vegetating 
varieties  are  essentially  the  same,  I  will,  to  avoid  con- 
fusion, speak  of  solid  and  cystic  tumors,  including, 
under  the  latter  term,  the  cystic  and  vegetating,  as 
the  vegetations  merely  represent  a  further  stage  of 
development  of  the  solid  growths. 

The  solid  connective  tissue  neoplasms,  which  con- 
stitute 50  per  cent,  of  the  entire  number,  correspond, 
for  the  most  part,  to  the  non-cystic  adenoceles,  ade- 
nomata, and  mammary  glandular  tumors,  and  to  those 
to  which  some  authors  prefix  the  term  adeno,  as  mi- 
nute examination  discloses  that  the  majority  contain 
the  remains  of  glandular  elements,  as  is  shown  in  fig. 
6.  These  may  be  entirely  normal,  or  the  epithelium 
may  have  sustained  changes  in  form  and  arrange- 
ment, or  the  acini  may  be  dilated,  or  they  may  be 
undergoing  obliteration,  or,  as  I  have  witnessed  in 
several  examples,  they  disappear  altogether.  In  ad- 
dition to  these  features,  there  are  very  few  specimens 
which  do  not  contain  enlarged  and  deformed  ducts, 
which  are  the  microscopic  representatives  of  the  irre- 
gular fissures,  slits,  or  cysts  that  exist  macroscopically 
in  the  cystic  tumors.  In  one  example  out  of  every 
seven  or  eight  they  are,  moreover,  occupied  by  cystoid 
cavities,  which  are  due  either  to  fatty  or  myxomatous 
degeneration  of  their  cellular  elements,  or  to  fatty 
and  mucoid  changes  of  the  irritated  epithelium  of  the 
acini  and  ducts.  In  the  former  events,  the  contents 
of  the  spaces,  which  have  no  epithelial  lining,  are  yel- 
lowish, greenish,  sanguinolent,  or  bloody,  while,  in 
the  latter,  they  are  serous,  mucoid,  or  even  pulta- 


38  CONNECTIVE  TISSUE  NEOPLASMS. 

ceous.  Whether  tlieir  origin  be  glandular  or  periglan- 
dular, they  represent  retrograde  metamorphoses,  and 
although  they  may  coexist,  they  must  not  be  con- 
founded, with  the  true  cysts  of  the  second  type  of 
tumor,  which  represent  a  further  stage  of  evolution, 
and  arise  in  an  entirely  different  way. 

The  cystic  connective  tissue  neoplasms,  which  em- 
brace 50  per  cent,  of  all  cases,  and  which  were  for- 
merly described  as,  or  included  under,  the  carcinoma 
hydatides  of  Sir  Charles  Bell,'  the  vesicular  scirrhus  of 
Benedict,'  the  hydatid  or  encysted  tumor  of  Sir  Astley 
Cooper,'  the  tuberous  cystic  tumor  of  Caesar  Haw- 
kins,* the  cystosarcoma  simplex,  proliferum,  et  phyl- 
lodes  of  Johannes  Mliller,"  the  serocystic  tumor  of 
Sir  Benjamin  Brodie,"  the  proliferous  mammary  cysts 
and  mammary  glandular  tumors  of  Sir  James  Paget,' 
the  cystoid  adenoceles  or  adenomas  of  Birkett,*  the 
cystoide  and  papillare  driisengeschwlilste  of  Foerster,' 
and  the  true  cystic  adenoceles  of  Bryant,"  are  now 
termed,  in  accordance  with  the  constitution  of  their 
stroma,  cystic  fibromata,  cystic  sarcomata,  and  cystic 
myxomata.  AVhen  the  cysts  are  barren  of  vegetations, 
the   tumors   are  simply  cystic   or   pericanalicular ; " 

>  Med.-Chir.  Trans.,  vol.  xii,  p.  224,  1823. 

'  Bemerkungcn  iiher  die  Kranl:  dcr  Brust-  und  Achseldriisen,  p.  73,  1825. 
^  Led.  on  the  Privc.  and  Prac.  of  Surga-y,  by  Tyrrell,  vol.  ii,  p.  163,  1825, 
and  Ills,  of  the  Dis.  of  the  Breast,  p.  20,  1829. 

*  London  Medical  Gazette,  vol.  i,  N.  S.,  p.  951,  1838. 

*  Ueber  dcr  Feinern  Bau,  etc.,  erste  Lief,  p.  56,  1838. 

*  Clinical  Lectures  on  Surgerii,  Phila.,  1846,  p.  206. 

'  Lond.  Med.  Gazette,  N.  S.,  vol.  xii,  p.  1039,  and  vol.  xiii,  p.  309,  1S51,  and 
Led.  on  Surg.  Path,  3d  ed.,  pp.  427  and  559,  1870. 

*  Gufs  Hosp.  Reps.,  ser.  3,  vol.  i,  p.  131,  '855,  and  Holmes's  System  of  Sur- 
gery, ante. 

9  Bdbch.  der  Path.  Anat.,  2d  ed.,  Bd.  ii,  p.  482,  1863. 

'"  Gu;/s  Hosp.  Reps.,  ser.  3,  vol.  x,  p.  106,  1864,  and  Swgo-y,  ante. 

"  Labbe  and  Coyne,  op.  cit. 


i 


AN-ATOMY.  39 

whereas  if  the  dilated  ducts  are  filled  more  or  less 
completely  by  intracystic  growths,  they  are  variously 
kno^^Ti  as  vegetating,  arborescent,  papillaiy,  prolifer- 
ous, endocanalicular,'  or  intracanalicular  tumors,"  and 
constitute  86  per  cent,  of  all  the  cystic  neoplasms  of 
the  mamma. 

As  was  first  demonstrated  by  Brodie,  and  con- 
firmed by  Reinhardt,'  the  cysts  are  due  to  ecstasia 
of  the  lactiferous  ducts,  which  are  very  apparent, 
even  on  the  cut  surfaces  of  growths  not  larger  than  a 
pullet's  egg,  as  variously  branched,  tortuous,  or  inter- 
communicating fissures,  slits,  or  clefts.  In  smaller 
growths,  of  the  size,  for  examj)le,  of  an  almond,  the 
initial  steps  of  the  change  can  be  followed  with  the 
microscope,  which  shows  conclusively,  as  is  repre- 
sented in  fig,  1,*  that  these  fissures  are  nothing  more 
than  the  ducts,  and  sometimes  the  acini,  the  w^alls  of 
which  have  been  mechanically  disparted  or  drawn 
asunder  by  the  eccentric  growth  of  the  peritubular 
and  periacinous  tissue  of  the  neoplasm.  In  some  spe- 
cimens, even  of  large  dimensions,  when,  in  addition 
to  enlargement  of  the  ducts,  there  is  progressive  new 
growth  of  their  membrana  propria,  the  fissures  are  so 
stretched  that  they  j)ersist  as  such,  their  inner  sur- 
faces being  merely  moistened  by  a  slight  amount  of 
clear  viscid  fluid.  In  others,  again,  through  the  accu- 
mulation of  their  contents,  they  assume  the  form  of 
rounded  or  elongated  and  wide  cavities,  and  may 

•  Labbe  and  Coyne,  op.  cit. 

'  Virchow,  op.  cit.,  Chapters  on  fibroma,  sarcoma,  and  myxoma. 
'Path,  und  Anat.  Untersuchen,  p.  126,  Berlin,  1852. 

*  From  a  section  of  a  fibroma,  of  two  years'  duration,  which  I  enucleated 
from  the  upper  and  outer  portion  of  the  left  mammary  of  a  single  woman, 
twenty-two  years  of  age. 


40 


CONNECTIVE  TISSUE  NEOPLASMS. 


even  contain  as  mucli  as  a  quart  of  serous,  mucous, 
lactescent,  or  sanguinolent  fluid.  In  tlie  majority  of 
examples,  however,  the  interstitial  or  pericanalicular 
tissue  grows  or  projects  into  the  deformed  ducts  as 


Fig.  1. 


Cystic  Fibroma. — Showing  transverse  and  longitudinal  sections  of  dilated  and 
elongated  ducts,  to  the  undermost  one  of  which  acini  are  attached,  lined 
by  columnar  epithelium. 


variously  shaped  masses,  as  the  papillary,  clavate, 
dendritic,  cauliflower,  spheroidal,  lobulated,  or  pedun- 
culated, with  broad  or  constricted  bases.  They  are 
covered  by  glandular  epithelium,  which  is  usually 
round  or  cuboid,  but  may  be  distinctly  columnar,  and 
they  may  either  lie  loosely  in  the  cysts,  or  fill  them 
entirely.  These  appearances  are  quite  visible  to  the 
unaided  eye,  even  in  small  tumors,  or  if  they  are  ap- 


Alf ATOMY. 


41 


parently  absent,  tliey  can  be  detected  on  minute  ex- 
amination, as  is  sliown  in  fig.  2/ 

The  microscopic  features  are  coarsely  followed  in 


Fig.  2. 


^%^  *\)i4;f '"""' 


Ctstic  Fibroma. — a  a.  Dilated  ducts  occupied  by  incipient  vegetations.  The 
epithelium  has,  for  the  most  part,  disappeared,  owing  to  its  detachment 
through  the  hardening  process  to  which  the  specimea  was  subjected. 
b.  Duct  partly  filled  by  hyperplastic  epithelium. 

the  larger  neoplasms,  so  that  the  intracanalicular  pro- 
jections are  very  evident  to  the  naked  eye,  as  in  fig. 
3.'     In  other  specimens,  as  in  fig.  4,'  they  constitute 

'  From  a  section  of  a  fibroma,  as  large  as  a  hickory-nut,  and  of  fourteen 
months'  duration,  which  I  enucleated  from  just  above  and  slightly  to  the  inside  of 
the  areola  of  the  right  mamma  of  a  healthy  single  woman,  twenty-five  years  of  age. 

*  From  a  specimen  removed  by  Professor  Gross  from  a  sterile  married 
woman,  thirty-three  years  of  age.  The  disease  was  of  three  years'  duration,  and 
affected  both  breasts.  The  intracanalicular  tubers  were  all  convex,  broadly 
based,  and  varied  from  one  third  of  an  inch  to  an  inch  in  height  and  breadth. 
On  section  the  majority  had  a  lobed  appearance,  while  a  few,  as  the  one  de- 
picted in  the  figure,  were  granular,  and  contained  dilated  ducts. 

*  From  a  specimen  in  the  cabinet  of  Professor  Gross,  which  is  devoid  of 
history. 


42 


CONNECTIVE   TISSUE  NEOPLASMS. 


pedunculated  growtlis,  wliicli  look  not  unlike  minia- 
ture bundles  of  grapes. 

In  their  histological  construction  they  do  not  dif- 


FiG.  3. 


Intracanalicular  Fibroma. — A  large  tuber,  a  portion  of  which  is  removed  to 
show  the  dilated  ducts  by  which  it  is  traversed,  is  seen  to  project  into  a 
greatly  enlaiged  duct  cyst.  What  may  be  termed  the  visceral  and  parietal 
layers  of  the  wall  of  the  cyst  are  clearly  shown. 

fer  from  the  remainder  of  the  growth,  and,  like  it, 
they  are   liable  to   various   transformations,  as   the 


Fir,.  4. 


Intracanalicular  Fibroma. — Showing  lobulated  masses  dependent  from  long 
and  narrow  pedicles. 

telangiectatic,  fatty,  and  myxomatous.     Apart  from 
softening  cysts,  they  may  themselves   give   rise   to 


AlfATOMr. 


43 


secondary  cystic  conditions,  wliicli  serve  to  impress 
one  with  the  idea  that  they  contain  glandular  tissue. 
These  cysts,  which  are  in  reality  follicular  or  space 
cysts,  or  modified  retention  cysts,  result  from  the 
compression  and  fusion  of  the  surfaces  of  contiguous 
papillary  vegetations  at  one  or  more  points,  so  that 
the  interpapillary  spaces  are  converted  into  recesses 
or  follicles,  as  is  shown  in  fig.  5,  from  one  of  my 


Fig.  5. 


Intracanalicular  Fibroma — Showing  three  papillae,  the  spaces  between  which 
are  converted  into  follicular  cysts.  In  the  cavity  on  the  ri!:;ht  the  epithe- 
lium is  seen  to  have  multiplied  ;  while  the  centi'al  papilla  is  projecting  an 
offshoot  into  the  cyst  to  its  left. 

specimens,,  the  epithelial  lining  of  which  secretes  a 
mucous  fluid. 

Independently  of  these  pseudotubular  glands  the 
vegetations  now  and  then  include  preexisting  glan- 
dular structure,  which  is  not  only  definable  by  the 
microscope,  but  is  indicated,  as  in  fig.  3,  by  the  di- 
lated ducts  which  traverse  them. 

In  addition  to  their  variable  consistence,  color, 
size,  shape,  and  transformations,  these  vegetations 
and  their  containing  cysts  are  of  interest  in  respect  to 


4A:  CONNECTIVE  TISSUE  NEOPLASMS. 

some  doubtful  views  tliat  are  entertained  as  to  tlieir 
mode  of  origin  and  the  relations  whicli  tliey  bear  to 
tlie  solid  connective  tissue  mammary  growths.  Paget, 
Bryant,  and  Bii'kett,  for  example,  teach,  in  the  first 
place,  that  they  may  arise  independently  of  dilated 
ducts ;  secondly,  that  when  they  are  found  in  connec- 
tion with  the  ducts,  they  develop  from  their  inner 
surface,  instead  of  making  their  way  into  them,  or 
rather,  displacing  and  deforming  them ;  and,  thirdly, 
that  they  give  rise  to  the  solid  tumors. 

With  regard  to  the  first  of  these  statements  Pa- 
get says  that,  "  it  is  possible  that  some  of  the  cysts 
that  bear  vascular  gro'v\i,hs  are  derived  through  trans- 
formation and  enormous  growth  of  some  elementaiy 
structure  of  the  gland."  Biyant  refers  them  to  a 
collection  of  fluid  in  the  connective  tissue  framework 
of  the  mamma ;  and  Birkett,  while  he  believes  that 
the  fissures  depend  upon  the  absence  of  connective 
tissue,  declares  that,  "  it  is  the  envelope  or  capside 
of  the  new  gro-wth  detached  from  its  sui'face  by  the 
accumulation  of  fluid  simply,  which  constitutes  the 
so-called  cysts,"  and  from  the  walls  of  which  the 
vegetations  spring.  From  the  facts,  however,  that 
these  cavities  are  lined  by  glandular  epithelium,  and 
can  frequently  be  traced  to  the  nipple;  that  the 
transformation  of  the  elementary  structure  results  in 
softening  or  extravasation,  instead  of  autogenous, 
cysts;  and  that  the  external  capsule  of  the  cystic 
groAvths  is  more  or  less  intimately  adherent  to  them, 
these  modes  of  cyst  formation  can  in  no  wise  be 
entertained. 

That  the  vegetations  grow  from  the  inner  surface 
of  the  cysts  is  not  more  tenable,  as  is  proved  by  their 


ANATOMY.  45 

minute  structure,  which,  is  that  of  the  mass  Tnth 
which  they  are  connected,  and  of  which  they  are  only 
prolongations ;  by  their  occasionally  including  glan- 
dular tissue ;  and  by  their  being  invested  by  the  wall 
of  the  duct  in  the  form  of  an  epithelial-clad  membrane. 
Even  the  delicate  dendritic  ve2;etations,  which  contain 
comparatively  little  connective  tissue,  are  pa23illary 
proliferations  of  the  pericanalicular  tissue  of  the  tu- 
mor, and  not  of  the  ducts  themselves. 

In  his  lecture  on  serocystic  tumors  of  the  breast, 
delivered  upward  of  thirty  years  ago,  Brodie  stated 
that,  "  under  certain  circumstances  the  cysts  become 
completely  filled  up  by  morbid  growths,  so  that  their 
cavities  are  obliterated,  the  tumor  being  thus  con- 
verted into  a  solid  mass  "  ;  but  he  resrarded  the  veo'e- 
tations  as  being  composed  of  "  organized  albumen  or 
fibrin." 

Paget,'  five  years  later,  taught  that  the  fusion  of 
th6  intracanalicular  gi'owths  with  the  walls  of  the 
cysts  transformed  the  cystic  into  solid  mammary 
glandular  tumors,  and  he  entertains  this  view  at  the 
present  day,  in  which  he  is  supported  by  Collis." 
From  a  minute  examination  of  thirty-one  specimens 
of  fibroma  and  sarcoma,  I  have  been  unable  to  trace 
such  a  transformation,  although  it  should  be  stated 
that  Goodhart,"  as  late  as  1872,  admits  the  transi- 
tion. In  small  growths,  fibromata,  for  example,  one 
readily  sees  that  the  fibrous  constituent  is  in  excess, 
and  that  the  glandular  tissue  is  sparse ;  that  the  first 
appearance  of  cystic  changes  in  the  growing  fibrous 

'  London  Med.  Gazeite,  ante. 

*  Tlie  Liag.  and  Treat,  of  Cancer  and  the  Tumors  Analogous  to  It,  p.  291. 

*  Edinburgh  Medical  Journal,  vol.  xvii,  part  2,  p.  1015. 


46  CONNECTIVE  TISSUE  NEOPLASMS. 

element  is  due  to  secondary  ectasia  of  tlie  ducts, 
wliicli  frequently  extends  to  tlie  acini ;  and  tliat  the 
vegetations  are  nothing  more  than  hernial  protrusions 
into  the  dilated  secreting  apparatus,  so  that  the  tumor 
must  originate  outside  of  instead  of  within  the  ducts. 
In  the  large  neoplasms,  which,  on  supei'ficial  examina- 
tion, appear  as  if  a  solid  growth  had  originated  by  the 
close  packing  and  adhesion  of  the  vegetations  to  the 
walls  of  the  cysts,  the  microscope  discloses,  as  I  have 
just  witnessed,  in  a  section  through  such  a  stuffed  lobe, 
that  the  fimbriated  ends  of  the  vegetations  are,  for 
the  most  part,  not  even  in  contact  with  the  cyst,  since 
only  two  of  the  eleven  touch  it  without  adhering. 
A  close  inspection,  moreover,  shows  that  when  the 
cysts  have  become  tilled  with  the  intruding  masses, 
the  latter  perforate  one  cyst  to  enter  another,  so  that 
neither  the  minute  nor  the  gross  appearances  indicate 
that  the  formation  of  a  cyst  is  the  first  step  in  the 
evolution  of  certain  mammary  tumors.  Directly  op- 
posed to  Paget's  doctrine  is  that  enunciated  five 
years  ago  by  Cadiat,*  who  teaches  that  a  solid  ade- 
noma, or  tumor  composed  of  hyperplastic  lacteal 
glands,  is  the  source  of  the  cystic  growths ;  in  other 
words,  that  the  mammary  glandular  tumor  of  Paget 
is  the  starting-point  of  cystic  and  vegetating  tumors, 
and  is  not  developed  from  them. 

In  addition  to  the  solid  ingrowths,  the  dilated 
ducts  usually  contain  fluid  of  a  mucoid  nature,  which 
may  be  bloody  if  the  vegetations  are  very  vascular. 
In  quantity  it  may  be  scarcely  more  abundant  than 
to  moisten  the  parts,  or  it  may  amount  to  many 
ounces,  and  serve  to  increase  the  lobulated  or  nodu- 

*  Robiii^  Journal  de  VAnat.  et  de  la  Phys.,  p.  183, 1874. 


lar  outline  of  the  neoplasms  of  whicli  it  forms  a  part. 
Now  and  then  it  is  discharged  by  the  nipple,  but 
rarely  in  large  quantities. 

The  connective  tissue  neoplasms  may  be  diffused, 
or  involve  the  entire  mamma,  as  happens  particularly 
in  fibromata,  when  they  constitute  the  affection  called 
elephantiasis  of  the  breast  by  Virchow,'  or,  as  it  is 
usually  kno^Mi,  general  hypertrophy  ;  or  the  morbid 
process  may  be,  and  generally  is,  restricted  to  a  single 
lobule  or  to  several  adjacent  lobules,  when  they  are 
denominated  tuberous,  lobular,  or  circumscribed. 
The  latter  are  invested  with  a  capsule  of  new  forma- 
tion, which  serves  to  distinguish  them  from  the  carci- 
nomatous tumors,  and  which  admits  of  their  being 
moved  about  in  all  directions,  although  in  many  in- 
stances their  deep  surface  is  attached  to  the  gland 
by  a  more  or  less  broad  pedicle,  in  which  vessels,  or 
glandular  tissue,  or  even  cysts,  can  be  detected.  This 
is  especially  true  of  the  fibromata  and  small  sarco- 
mata, so  that,  as  I  have  not  infrequently  witnessed,  a 
portion  of  the  breast  has  to  be  removed  along  with 
the  tumor.  In  such  cases,  if  it  happens  that  an 
operation  be  conducted  during  lactation,  milk  may 
be  found  in  the  embedded  lobules,  as  in  an  example 
of  adenoid  sarcoma  recorded  by  Billroth ; "  or  that 
fluid  may  be  discharged  by  the  wound,  as  in  two 
instances  of  fibroma  from  the  practice  of  Cras,'  and 
Cruveilhier,^  and  in  one  of  recurrent  spindle-celled 
sarcoma  reported  by  Le  Fort.' 

'  Op.  dt.  Trad.  Fran?.,  vol.  i,  p.  325. 

*  VirchovPs  Archiv,  Bd.  xviii,  p.  68. 

®  Bull,  et  Mem.  de  la  Soc.  de  Chir.,  vol.  iii,  p.  13. 

*  Ibid.,  p.  153. 

*  Ibid.,  vol.  ii,  p.  487. 


48  CONNECTIVE  TISSUE  NEOPLASMS. 

In  tlie  circumscribed  or  lobular  neoplasms  the  re- 
mainder of  tlie  gland  is,  wlien  the  growtli  is  volumi- 
nous, pushed  aside,  flattened,  spread  out,  or  even  atro- 
phied, although  it  now  and  then  happens  in  sarcoma 
and  myxoma  that  it  is  invaded  by  the  rapidly  prolif- 
erating tissue.  It  is  also  not  very  uncommon  for  the 
investing  capsule  and  overlying  tissues  to  give  way 
and  permit  a  portion  of  the  mass  to  protrude  exter- 
nally. In  a  unique  case  recorded  by  Satterthwaite,' 
of  New  York,  an  intracanalicular  fibroma  protruded 
through  the  dilated  ducts,  without  the  intervention 
of  ulceration,  so  that  the  nipple  was  surmounted  by  a 
mass  of  tissue  which  was  eight  lines  high,  and  looked 
like  exuberant  granulations.  These  neoplasms  also 
present  some  other  features  in  common,  but  as  they 
will  be  described  under  the  individual  tumors,  they 
need  not  detain  us 

'  The  Medical  Record,  p.  635,  1874. 


CHAPTEE  Y. 

FIBROMA. 

Neoplasms  composed  of  hyperplastic  connective 
tissue,  in  wliicli  normal  or  variously  altered  glandular 
elements  are  sparingly  interspersed,  are  classified  as 
fibromata.  From  the  persistence  mainly  of  the  acini, 
they  are  included  by  Birkett '  in  his  first  group  of 
adenomata,  which  he  describes  as  being  "compact, 
dense,  firm,  fibrous,  lobulated,  and  invested  by  their 
own  fibrous  capsule  "  ;  and  they  are  synonymous  with 
the  solid  fibroid  glandular  tumors  of  Foerster,'  the 
adenomata  "vvith  predominance  of  stroma  of  Broca,' 
and  the  corps  fibreux  of  Cruveilhier.*  That  they  form 
at  least  a  part  of  the  mammary  glandular  tumors  of 
Paget  is  evident  from  the  statement,  that  the  connec- 
tive tissue  was  very  abundant  in  most  of  the  speci- 
mens he  had  examined/  From  the  very  frequent 
presence  of  preexisting  lacteal  glands  in  their  midst, 
Green,'  Duplay,"  and  Billroth '  term  them  adenofibro- 

'  Holmes's  System  of  Surgery,  vol.  v,  p.  255. 
2  Op.  ci(.,  BJ.  ii,  p.  481. 
^  Op.  cii.,  t.  ii,  p.  441. 

*  Ante. 

*  Op.  cit.,  foot-note,  p.  559. 

*  Op.  cit.,  p.  141. 
'  Op.  cii.,  p.  615. 

8  Hdbch.  von  Pitha  und  Billroth,  Bd.  iii,  Abth.  2,  Lief  i,  p.  89,  and    Chir. 
Klinik,  Wien,  1871-"76,  p.  261. 
4 


50  FIBROMA. 

mata.  Klebs '  recognizes  an  almost  pure  fibroma  and 
an  adenofibroma ;  while  Yircliow,''  Rosenstirn/  Mo- 
nod,*  Cornil  and  Ranvier,'  Lannelongue/  Tripier/ 
Labbe  and  Coyne/  and  other  modern  investigators 
describe  them  merely  as  fibromata.  The  vegetating 
variety,  properly  denominated  cystic  fibroma,  is  equiv- 
alent to  the  papillare  driisengeschwulst  *  of  Foerster, 
the  cystosarcoma  fibrosum  of  Rindfleisch,  the  fibroma 
intracanaliculare  papillare  of  Virchow,  the  fibroma 
endocauaniculare  of  Labbe  and  Coyne,  the  cystoid 
adenoma  of  Birkett,  the  true  cystic  adenocele  of  Bry- 
ant, and  the  proliferous  mammary  cyst  of  Paget. 

Circumscribed  fibromata  are  spherical,  rounded,  or 
ovoid,  and  have  a  nodular,  bossed,  or  lobulated  out- 
line. Their  consistence  is  usually  firm  and  elastic, 
or  hard  when  they  are  not  succulent,  or  unequal 
when  the  fluid  contents  of  the  cysts  are  in  excess^ 
in  which  event  they  are  elastic,  or  soft  and  fluctu- 
ating over  the  more  prominent  bosses,  but  firm  else- 
where. On  section  they  may  be  dry,  white,  nacra- 
ceous,  or  opaque-white,  dense,  and  compact,  and  cry 
under  the  knife,  and  the  interlacing  bundles  of 
fibrous  tissue  may  be  arranged  concentrically  around 
centres  which  project  above  the  level  of  the  cut  sur- 
faces.   Minute  examination  of  growths  which  present 

»  Op.  «7.,  pp.  1181  and  1199. 

*  Op.  ciL,  p.  325. 

2  Virchoio^s  Archiv,  Bd.  Ivii,  p.  163. 

*  Arch.  Gen.,  scr.  6,  vol.  xxv,  p.  23. 
»  Op.  cit.,  p.  159. 

*  Diet,  dc  Med.  et  de  Chir.  Prat.,  t.  xxi,  p.  655. 

'  Diet.  Encyc.  des  Sciences  Med.,  ser.  ii,  t.  iv,  p.  394. 
8  Op.  cit,  p.  252. 

^  Op.  cit.,  p.  544.     For  the  other  references  to  the  works  contained  in  this 
paragraph,  consult  page  38. 


ANATOMY. 


51 


these  peculiarities,  shows,  as  in  fig.  6,'  that  they  are 
composed  of  dense  bundles  of  mature  fibrous  tissue, 
which  is  almost  or  entii^ely  devoid  of  corpuscles,  and 
that  the  small  projections  correspond  to  acini.     This 


Fio.  6. 


Fibroma. — New  growth  of  mature  connective  tissue,  with  intercalated  dilated 
acini,  a  a  a,  tliCepithelial  cells  of  which  have  undergone  irritative  hyper- 
plasia.     The  stained  nuclei  of  the  cells  alone  are  shown. 

type  corresponds,  therefore,  to  tlie  neoplasms  former- 
ly called  fibroid  or  desmoid.  In  other  specimens, 
bands  of  young,  wavy  connective  tissue  interlace  in 
every  direction.  Such  tumors  are  more  or  less  juicy 
or  moist,  and  of  a  glistening  whitish,  grayish-white, 
or  rosaceous  tint,  and  represent  the  majority  of  fibro- 
mata.    In  rapidly  growing  examples  the  minute  struc- 

'  From  a  section  of  a  tumor,  as  large  as  a  walnut,  and  of  fourteen  months' 
duration  enucleated  from  the  upper  and  outer  portion  of  the  right  mamma  of  a 
married  and  prolific  lady  forty-two  years  of  age. 


52  FIBROMA. 

ture  is  that  of  recent  connective  tissue  abounding  in 
cellular  elements. 

The  smallest  vegetating  tumors  have  a  lobed  ap- 
pearance, while  the  macroscopic  features  of  the  larger 
ones  vary  in  accordance  with  the  transformations  to 
which  they  are  liable.  Thus,  while  the  mass  of  the 
growth  may  be  firm  and  of  a  milk-white  color,  the 
vegetations  are  not  infrequently  softer  and  more 
transparent.  When  they  are  very  vascular,  their  tint 
is  rosaceous,  or  decidedly  red,  or  red  in  lines,  or  even 
ecchymotic.  A  yellowish  hue  is  indicative  of  fatty 
changes,  while  myxomatous  degeneration  is  charac- 
terized by  areas  of  gelatinous  appearance. 

Inflammation  and  suppuration  of  fibroma  are  very- 
uncommon,  and  fungous  protnision  was  met  with  in 
only  three  of  the  fifty  cases  which  I  have  collected. 
In  an  example  of  intracanalicular  tumor,  recorded  by 
Gotzmann  '  from  the  practice  of  Grohe,  incision  gave 
vent  to  pus,  and  considerable  masses  protruded, 
which  gradually  sloughed  off,  and  the  opening  closed. 
The  incised  part  again  opened  in  eighteen  months, 
and  was  the  seat  of  obstinate  hemorrhage.  In  the 
case  of  Fergusson"  there  was  an  immense  pouch, 
which  opened  on  the  surface  in  the  form  of  two  lips, 
the  fissure  between  which  was  large  enough  to  admit 
three  fingers.  In  that  of  Labbe,"  a  tumor  of  nearly 
thirty-four  years'  duration  had  ulcerated  during  the 
last  two  months  of  its  existence,  and  protruded  from 
a  large  cyst  as  a  mushroom-like  mass  of  the  volume 
of  one-third  of  a  fist.     Its  surface  was  red  and  mam- 

'  Ucher  das  Intracanaliculdre  Fibrom  der   WeiUichen  Brustdriise.      Inaug. 
Disser.,  Straslund,  1 867. 

*  Trans.  Fath.  Soc.  London,  vol.  iv,  p.  273.  ?  Op.  cit.,  p.  275. 


DEGENERATION'S.  63 

millated,  and  discliarged  bloody  pus.  It  is  interesting 
to  note,  from  a  diagnostic  standpoint,  that  tliese  were 
all  examples  of  vegetating  growths,  and  tliat  the  skin 
around  the  ulcer  was  normal  as  respects  freedom  from 
infiltration  and  adhesion  to  the  protruding  mass. 

The  degenerations  of  fibromata  are  the  cystoid, 
fatty,  myxomatous,  osseous,  calcareous,  and  telangiec- 
tatic, but  they  are  infrequent.  In  about  4  per  cent, 
of  all  examples  they  may  be  the  seat  of  cysts,  due 
either  to  fatty  or  mucoid  transformation  of  the  epi- 
thelium of  the  acini,  or  to  myxomatous  change  of  the 
connective  tissue.  In  addition  to  the  latter,  there  may 
also  be  fatty  metamorphosis,  and  in  this  event  the 
growth  may  contain  blood  or  extravasation  cysts.  In 
6  per  cent,  of  all  cases,'  provided  they  are  of  many 
years'  duration,  the  mineral  salts  may  be  interspersed 
throughout  limited  portions  of  the  mass,  so  as  to 
impart  to  it  the  appearance  of  spongy  bone  ;  or  they 
may  be  aggregated  into  a  densely  hard  concretion, 
which,  as  recorded  by  Cniveilhier,  may  resemble  in 
size  and  configuration  the  head  of  the  femur ;  or,  as 
in  the  case  of  Monteils,  they  may  form  plates  sur- 
rounding the  fibrous  tissue,  some  of  which  contain 
osteoblasts.  Ossification  is  very  uncommon,  the  only 
example  of  that  occurrence  of  which  I  have  any 
knowledge  being  one  of  a  true  spongy  osteoma,  as 
large  as  a  pigeon's  e^g,  contained  in  a  cystic  myxo- 
matous fibroma  removed  by  Leloir.' 

Although  they  are,  as  a  rule,  only  moderately 
vascular,  fibromata  undergo  telangiectatic  transforma- 

'  Cases  of  Labbe,  op.  cif.,  p.  2Y0 ;  Monteils,  Bull,  de  la  Roc.  de  Chir.,  ser. 
3,  vol.  i,  p.  472 ;  and  Cruveilhier,  Bidl.  de  la  Soc.  Anat.,  t.  xlviii,  p.  344. 
2  Gaz.  Med.  de  Faris,  No.  52,  1878. 


54  FIBROMA. 

tion  in  one  case  out  of  every  eight  and  one-tliird,* 
whicli  is  usually  associated  with  rapid  growth,  and  is 
indicated  in  one  haK  of  the  examples  by  a  bloody 
discharge  from  the  nipple.  In  these  cases  of  in- 
creased vascularity,  which,  as  well  as  the  calcareous 
degeneration,  appears  to  be  confined  to  the  cystic 
fibromata,  the  vegetations  are  pervaded  by  large  ves- 
sels, to  the  rupture  of  which  may  be  ascribed  the 
more  or  less  transformed  blood  that  is  found  in  the 
dilated  ducts,  and  the  hemorrhages  which  occur 
when  they  protrude  externally. 

Fibrous  tumors  of  the  mamma  are  usually  soli- 
tary. Thus  of  50  examples,  only  9  were  multiple, 
two  or  more  growths  being  present  in  one  breast  in 
three,  and  in  both  in  six.  When  single  they  are,  for 
the  most  part,  peripheral,  being  found  in  the  upper 
half  of  the  gland  and  toward  its  outer  side  in  rather 
more  than  three-sixths,  above  and  internally  in  less 
than  two-sixths,  and  in  the  \ncinity  of  the  nipple  and 
in  the  lower  segment  of  the  organ  in  one-sixth  of  all 
cases.  They  are  generally  quite  superficial,  and,  in 
rare  cases,  or  once  in  every  sixteen,  project  beyond 
the  level  of  the  skin  as  pendulous  or  pedunculated 
gro^vths." 

They  have  been  met  mth  as  early  as  the  twelfth 
and  as  late  as  the  fifty-sixth  year,  the  average  age  of 
their  first  observation  being  28'5  years,  but  they  are 
uncommon  before  puberty  and  after  the  fifth  decade. 
Of  the  50  cases, 

'  Cases  of  Labbe,  op.  cit.,  pp.  206,  275,  and  397;  De  Morgan,  Trans.  Path. 
Soc.  London,  vol.  xxi,  p.  352  ;  Cruveilhier,  ut  supra  ;  and  Lebreton,  Bull.  Soc. 
Anat,  t.  xliii,  p.  282. 

*  De  Morgan,  Trans.  Path.  Soc.  London,  vol.  xix,  p.  393  ;  Paget,  op.  cit., 
p.  564 ;  and  Cras,  Bull,  et  Mem.  de  la  Soc.  de  Chir.,  t.  iii,  p.  13. 


ETIOLOGY.  55 

11  appeared  between  10  and  20  years. 
18         "  "        20    "    30      " 

11         "  "        30    "    40      " 

7        "  "        40    "    50      " 

3         "  "        50    "    60      " 


Of  tte  entire  number,  6,  or  12  per  cent.,  occurred  be- 
fore the  sixteenth  year,  namely  at  the  ages  of  12,  13, 
14,  14,  14,  and  15,  or  during  the  developmental  state 
of  the  mamma ;  34,  or  68  per  cent.,  appeared  between 
the  sixteenth  and  fortieth  years,  or  at  a  period  when 
the  breast  and  the  genital  organs  are  functionally 
most  active ;  and  10,  or  20  per  cent.,  after  the  for- 
tieth year,  or  during  the  period  of  their  functional 
decline.  It  is,  moreover,  interesting  to  note  that 
cystic  fibroma  develops  later  in  life  than  the  solid 
variety,  since  the  average  age  at  which  the  former 
was  fii^st  noticed  was  36'9  years,  against  23-9  years 
for  the  latter.  Hence  it  may  be  said  that  non-vege- 
tating fibromata,  which  represent  six-tenths  of  the  en- 
tire number,  are  essentially  outgrowths  of  the  young 
and  active  mamma,  while  vegetating  fibromata  are 
outgrowths  of  the  mature  gland. 

Nineteen  of  the  patients  were  single  when  the 
tumor  was  first  observed,  and  twenty-two  were  mar- 
ried, while  the  social  condition  is  not  stated  in  nine. 
Of  the  married  women,  thirteen  had  more  than  one, 
and  five  had  one  child,  but  four  of  these  had  never 
suckled ;  two  were  barren ;  and  the  question  of  chil- 
dren is  not  mentioned  in  two.  In  two  the  disease 
developed  during  lactation. 

Of  thirty-three  cases,  in  which  the  menstrual  func- 
tion is  recorded,  thirty  were  regular,  two  were  irregu- 
lar, and  one  was  the  subject  of  metrorrhagia.     Two 


56  FIBROMA. 

of  tlie  patients  after  the  fiftieth  year  were  menstru- 
ating, while  of  the  young  subjects  it  is  certain  that 
the  catamenia  had  appeared  in  one  at  the  age  of  four- 
teen. Assuming,  in  the  remaining  five  and  in  one 
woman  of  fifty-six  years,  that  the  menses  had  either 
not  appeared  or  had  ceased,  it  is  evident  that  fibro- 
mata are  developed  principally  during  the  menstrual 
epoch  of  life,  since  it  is  not  shown  in  a  single  instance 
that  they  appeared  after  the  menopause.  These  facts, 
when  considered  in  connection  mth  the  statements 
concerning  the  social  condition  of  the  patients,  demon- 
strate conclusively  that  neither  celibacy  nor  disordered 
nor  arrested  menstiiiation  is  an  important  agent  in 
their  production. 

In  only  six  instances,  or  one  in  every  eight  and 
one-third,  was  the  tumor  traceable  to  injury,  while 
in  none  did  it  ajDpear  to  be  inherited.  The  general 
health  of  the  patients  was,  as  a  rule,  excellent. 

The  gi'owth  of  fibromata  is  slower  than  that  of  the 
other  connective  tissue  tumors,  but  it  is  veiy  variable, 
and  seems  to  be  influenced  by  the  presence  or  absence 
of  vegetations.  Of  the  solid  variety,  the  smallest 
that  I  have  met  ^dth  attained  a  diameter  of  half  an 
inch,  and  a  thickness  of  three  eighths  of  an  inch,  in 
twelve  months,  and  a  personal  experience  with  eleven 
cases  shows  that  they  rarely  exceed  the  volume  of  a 
large  walnut  in  three  years.  Even  at  the  end  of  ten 
years  they  may  be  limited  to  that  size,'  or  measure 
only  three  inches  in  diameter  in  eighteen  years."*  A 
breadth  of  an  inch  and  three  quarters  in  six  months 
is  the  most  rapid  growth  that  I  have  witnessed.    The 

'  Labbe  et  Coyne,  op.  cit.,  p.  388. 

'  Muriel,  Trans.  Path.  Soc.  London^  vol.  viii,  p,  384. 


GROWTH.  57 

largest  examples  tliat  I  find  recorded  were  of  the 
size  of  a  goose's  egg  in  four  years;*  or  measured 
nearly  twelve  inelies  in  length,  and  weighed  seven 
pounds  in  twelve  years ; "  or  had  a  circumference  of 
twenty-two  inches,  and  weighed  four  pounds  in 
twenty  years;'  or  attained  the  volume  of  two  fists, 
and  weighed  upward  of  twelve  pounds  in  twenty-one 
years/  On  the  whole,  the  rate  of  their  growth  may 
be  computed  at  about  two-thirds  of  an  inch  a  year. 

Cystic  fibromata  increase  more  quickly  and  ac- 
quire a  larger  size,  as  a  rule,  than  the  preceding  vari- 
ety. While  it  is  true  that  they  may  require  twelve 
months  to  reach  the  volume  of  a  small  chestnut,'  or 
six  months,"  eighteen  months,'  two,*  three,"  and  even 
four  years,"  to  attain  the  dimensions  of  a  hen's  egg, 
they  grow,  on  the  other  hand,  to  the  size  of  a  double 
fist  or  foetal  head  in  two  years  and  a  half"  or  six 
years,"  of  an  adult  head  in  one  year  "  or  twenty-five 
years,"  or  have  a  circumference  of  twenty -nine  inches, 
and  weigh  eight  pounds  in  six  years,"  or  weigh  twen- 
ty-nine pounds  in  seven  years."  A  peculiarity  of 
their  growth  is  that,  while  they  may  have  been  sta- 
tionary or  have  progressed  slowly  for  a  long  time, 
they  suddenly,  and  without  obvious  cause,  begin  to 

'  Schuh,  Chirurgie  und  Operationslehre,  p.  311. 

"  Paget,  op.  cit.,  p.  664. 

^Montcils,  £uU.  de  la  Soc.  de  Chir.,  ser.  3,  t.  i,  p.  472. 

*  Cras,  Bull,  et  Mem.  de  la  Soc.  de  Chir.,  vol.  iii,  p.  13. 

*  Labbe  et  Coyne,  op.  cit.,  p.  397. 

6-1"  Ibid.,  pp.  448,  190,  131,  408,  and  264. 
"  Demarquay,  Bull,  de  la  Soc.  Anat.,  t.  xliii,  p.  492.    Paris,  1868. 
'*  Labb6  et  Coyne,  op.  cit.,  p.  259. 
'^  Lebreton,  ante. 

"  Labb6  et  Coyne,  op.  cit.,  p.  270. 

'*  De  Morgan,  Tram.  Path.  Soc.  Bond.,  vol.  xxi,  p.  352. 
"  Glicrini,  Annali  Univ.  di  Med.,  Feb.,  1878. 


58  FIBROMA. 

increase  rapidly,  so  that  a  nodule  tliat  lias  remained 
of  tlie  size  of  a  walnut  for  five  years  and  a  haK  reaches 
the  volume  of  a  double  fist  in  six  months,'  or  a  tumor 
v^hich  has  taken  twenty -four  years  to  equal  the  size 
of  an  orange  attains  that  of  an  adult  head,  and  weighs 
nearly  six  pounds  in  an  additional  year.'  Under  these 
circumstances  the  neoplasm  will  be  found  to  be  very 
vascular,  or  contain  blood-cysts,  or  a  large  quantity  of 
fluid.  Hence  the  mode  of  increase  is  of  importance 
as  an  aid  in  the  diagnosis  of  the  variety  of  fibroma,  a 
slowly  and  regularly  gro"\ving  tumor  indicating  free- 
dom from  cysts  and  vegetations,  and  a  suddenly  and 
rapidly  increasing  tumor,  with  decided  enlargement 
of  its  bosses,  indicating  the  accumulation  of  fluid  con- 
tents and  intracanalicular  vegetations. 

It  now  and  then  happens  that  fibromata  grow  very 
rapidly  during  pregnancy,  as  in  the  case  reported  by 
Cras,  while,  in  about  six  per  cent,  of  all  examples, 
they  become  larger  during  the  menstrual  discharge 
and  subside  at  its  termination."  In  one  case  the 
tumor  became  harder  and  fuller  just  before  the 
appearance  of  the  menses,  but  returned  to  its  former 
consistence  and  volume  when  the  flow  was  estab- 
lished." In  an  instance  recorded  by  Fergusson,"  it 
increased  very  rapidly  after  the  menopause ;  while, 
in  a  unique  example  reported  by  De  Morgan,"  the 
breast  suddenly  doubled  its  size  during  a  severe  at- 
tack of  gout  in  the  toe,  but  returned  to  its  original 
dimensions  with  the  disappearance  of  the  disease. 

'  Labbe  et  Coyne,  op.  cit.,  p.  259. 

2  Ibid.,  p.  270. 

^  Ibid.  ;  De  Morgan,  ante  ;  and  Muriel,  ante. 

^  Labbe  et  Coyne,  op.  cit.,  p.  190. 

^  Ante.  6  ^„^g_ 


COMPLICATIONS.  59 

Througliout  tlieir  entire  life,  as  a  rule,  tlie  skin 
remains  mobile  and  normal  in  texture  and  color ;  tlie 
subcutaneous  veins  are  not  enlarged ;  tlie  nipple  is 
natural ;  the  neigliboring  lymphatic  glands  are  not 
involved ;  and  the  tumors  are  free  from  superficial  or 
deep  attachments. 

To  these  general  statements  there  are  some  excep- 
tions. In  two  cases  the  skin  was  adherent,  but  to  a 
limited  extent  only  in  one ;  in  tw^o  it  was  red,  and  in 
one  of  these,  at  points,  almost  pui'ple ;  while  in  three, 
as  has  been  ali'eady  mentioned,  it  ulcerated.  The 
superficial  veins  were  tortuous  and  dilated  in  three. 
The  nipple  was  depressed  in  two.  In  one  the  neo- 
plasm was  so  closely  connected  with  the  outer  border 
of  the  pectoral  muscle  that  some  of  its  fibres  had  to 
be  removed  with  it;  while  in  another  it  adhered 
firmly,  by  tw^o  prolongations,  to  the  periosteum  of 
the  sternum.  In  not  a  single  instance  were  the 
lymphatic  glands  enlarged. 

In  about  one  case  out  of  every  seven  of  cystic 
fibromata  there  is  a  discharge  from  the  nipple,  but  this 
symptom  does  not  appear  to  be  present  in  the  solid 
form  of  fibrous  tumor.  In  an  example  recorded  by 
Labbe,'  a  spontaneous,  although  scanty,  escape  of  a 
whitish  fluid  preceded  the  detection  of  the  new 
growth  by  two  months,  when  it  became  bloody.  In 
a  patient  under  the  care  of  Guyon,"  a  sanguinolent 
discharge  was  induced  by  pressure  upon  the  breast, 
but  it  had  ceased  for  several  years  before  the  tumor 
was  extirpated.  In  a  third  case,'  there  were  several 
hemorrhages  by  the  nipple  during  the  rapid  increase 
of  the  tumor,  or  during  the  last  month  of  its  exist- 

*  Op.  ciL,  p.  397.  2  Ibid.,  p.  206.  ^  Lebreton,  ante. 


60  FIBROMA. 

ence.  In  all  of  these  examples  the  cysts  were  more 
or  less  completely  filled  with  highly  vascular  vegeta- 
tions, so  that  a  bloody  discharge  is  indicative  of  that 
condition. 

Fibrous  tumors  of  the  breast  are  by  no  means 
indolent,  since,  of  41  cases  in  which  pain  is  referred 
to,  that  symptom  was  present  in  24,  or  5  8 "5  j^er  cent., 
while  it  was  absent  in  17.  Attention  was,  however, 
first  called  to  the  affection  by  suffering  in  only  2  of 
the  entire  number,  while  in  the  remainder  it  declared 
itself  after  the  discovery  of  the  tumor.  In  13,  or 
rather  more  than  one-half,  the  pain  was  of  an  inter- 
mittent, severe  shooting,  darting,  lancinating,  or  neu- 
ralgic character,  while  in  11  it  was  slight  and  evanes- 
cent, usually  darting,  but  not  infrequently  dull  and 
aching.  In  6  it  did  not  appear  until  the  tumor  began 
to  increase  rapidly ;  in  2  it  was  experienced  only  at  the 
menstrual  period ;  in  2  it  grew  worse  at  that  time, 
and  in  1  dming  lactation ;  while  in  1  the  pain  was 
aggravated  after  the  cessation  of  the  catamenia.  In 
the  examples  of  ulceration  of  the  skin  and  fungous 
protrusion,  the  suffering  was  slight ;  in  one,  indeed, 
there  was  no  pain  at  all,  but  the  mass  was  exquisitely 
tender  on  handling.  Including  this  case,  only  five 
were  sensitive.  In  one  of  my  own,  a  tumor  not 
larger  than  a  bean  was,  for  the  last  three  months  of 
its  existence,  as  intolerant  of  manipulation  as  a  pain- 
ful subcutaneous  tubercle.  It  had  existed  for  one 
year  in  the  right  mamma  of  a  prolific  female,  aged 
forty-two,  from  whose  left  breast  a  similar  gro^i;h 
was  removed  six  years  previously  in  Saxe- Weimar. 
In  three  examples  the  pain  and  tenderness  were  so 
great  as  to  occasion  what  is  known  as  the  ii'ritable 


REOUREENGE.  61 

tumor  of  tlie  breast,  and  in  none  of  these  did  tlie 
growth  exceed  the  volume  of  a  small  walnut.  Hence, 
while  it  is  true  that  amyelenic  neuromata  occur  in 
the  mamma,  as  has  been  demonstrated  by  Tripier  *  in 
two  instances,  it  is  highly  probable  that  the  small 
growths  which  excite  so  much  suffering  are  composed 
essentially  of  indurated  fibrous  tissue. 

Recurrence  of  fibromata  is  met  with  rather  more 
than  once  in  every  sixteen  cases.  Thus,  Notta* 
enucleated  a  calcifying  vegetating  tumor  of  twenty- 
five  years'  duration,  as  large  as  an  adult  head,  and 
weighing  five  pounds,  from  the  breast  of  a  prolific 
woman  of  fifty-two.  At  the  expiration  of  six  months 
she  detected  a  new  growth,  of  the  volume  of  a  wal- 
nut, at  the  cicatrix,  which,  in  three  months,  had  at- 
tained the  size  of  a  child's  head.  As  it  soon  ceased 
to  increase,  and  as  it  caused  no  pain,  she  declined 
further  interference.  De  Morgan^  excised  a  fibrous 
tumor  as  large  as  an  egg  from  a  woman  twenty -two 
years  of  age.  Another  growth  made  its  appearance 
in  twelve  months,  which,  in  six  years,  when  it  was 
removed,  had  acquired  the  volume  of  a  small  cocoa- 
nut,  and  was  pendulous.  It  was  a  coarse  fibroma 
with  withered  ducts.  In  a  remarkable  case,  recorded 
by  Rosenstirn,*  a  tumor  of  one  year's  standing,  and 
seated  in  the  left  mamma  of  a  prolific  woman  of 
forty-five,  was  enucleated  in  April,  1855.  In  March, 
1860,  a  growth  of  six  months'  duration  was  removed 
from  the  ris-ht  breast.     Four  additional  tumors  were 

o 

'  Diet.  Encyclop.  des  Sciences  3fedicales,  ser.  2,  t.  iv,  p.  408. 
'  Labbe  et  Coyne,  op.  cit.,  p.  270. 

*  Trans.  Path.  Soc,  London,  vol.  xix,  p.  393. 

*  Virchovj's  Archiv,  Cd.  Ivii,  p.  166. 


62  FIBROMA. 

extirpated  from  tlie  left  mamma  in  March,  1861, 
August,  1862,  August,  1866,  and  September,  1869, 
and  two  from  tlie  right  breast  in  1862  and  1869. 
They  were  all  traversed  by  enlarged  and  deformed 
ducts. 

These  illustrations  of  recurrence  do  not  denote 
local  malignity,  but  merely  indicate  that,  in  some 
women,  there  is  a  tendency  to  the  formation  of  mul- 
tiple fibrous  growths,  so  that  in  these  cases  it  was  a 
question  either  of  the  f ui'ther  development  of  a  nodule 
which  was  overlooked  at  the  time  of  operation,  or  of 
the  successive  appearance  of  similar  tumors  in  por- 
tions of  the  gland  that  remained  behind.  In  all  of 
these  examples  the  growths  were  simply  enucleated ; 
but  even  when  the  gland  has  apparently  been  entire- 
ly removed,  it  need  not  excite  surprise  if  fibromata 
subsequently  make  their  appearance,  since  outstand- 
ing lobules  are  sometimes  disseminated  throughout 
the  entire  mammary  region,  and  even  in  the  axilla, 
and  may  readily  escape  the  eye  of  the  surgeon. 

Other  evidences  of  the  innocent  nature  of  fibro- 
mata are  the  absence  of  enlargement  of  the  associated 
lymphatic  glands  and  of  secondary  deposits  in  the 
viscera.  Their  benignity  is,  moreover,  demonstrated 
by  the  facts  that  they  had  existed,  on  an  average,  for 
five  years  and  eight  months  before  they  were  sub- 
jected to  the  knife,  and  that  the  total  duration  of  life 
from  their  first  observation  to  the  date  of  the  final 
reports  averaged  fourteen  years. 

Although  they  are  not  malignant,  fibromata  may, 
in  their  open  and  fungating  state,  prove  destructive 
to  life  through  profuse  suppuration  and  hemorrhage, 
or  through  the  injurious  effects  exerted  upon  neigh- 


LIAGN-QSIS.  63 

boring  organs.  Thus,  Foerster  *  describes  a  solid  tu- 
mor, eleven  inches  long,  eight  broad,  and  four  inches 
and  a  half  in  thickness,  which  produced  absorption 
of  a  portion  of  the  seventh  rib,  and  penetrated  the 
thorax,  where,  covered  by  the  pleura,  it  formed  a 
mass  seven  inches  long,  five  broad,  and  three  inches 
and  a  half  thick,  which  rested  upon  the  diaphragm, 
pushed  the  lung  upward  and  completely  compressed 
its  lower  lobe,  dislocated  the  heart  to  the  right,  and 
curved  the  vertebral  column  to  the  opposite  side. 

The  diagnosis  of  fibromata  is  based  upon  their 
indolent  and  insidious  origin,  their  great  mobility, 
peripheral  situation,  firm  consistence,  lobulated  out- 
line, slow  growth,  moderate  dimensions  for  the  period 
of  their  existence,  freedom  from  alterations  in  the 
skin,  nipple,  subcutaneous  veins,  and  lymphatic  glands, 
slight  liability  to  ulcerate  and  fungate,  and  to  a  dis- 
charge from  the  nipple,  tendency  to  be  painful  dur- 
ing their  progress,  and  upon  their  greatest  frequency 
between  the  sixteenth  and  thirty-fifth  years,  or,  on 
an  average,  at  the  twenty-eighth  year. 

The  distinction  between  the  solid  and  cystic  va- 
rieties may  be  made  by  attention  to  the  following 
points :  The  former  appear,  on  an  average,  at  the 
twenty-third  year ;  twenty-one  per  cent,  develop  before 
the  age  of  sixteen,  and  seventy-five  per  cent,  before 
the  thirtieth  year.  They  are  uniformly  firm  or  hard, 
never  fungate,  nor  are  they  marked  by  a  bloody  dis- 
charge from  the  nipple.  The  latter  are  never  seen 
before  the  sixteenth  year;  occur,  on  an  average,  at 
the  thirty-sixth  year ;  and  only  thirty-five  per  cent, 
originate  before  the  age  of  thirty.     Their  consistence 

'  Op.  cit.,  Bd.  ii,  p.  481. 


64 


FIBROMA. 


is  unequal,  being  firm  at  points,  and  soft  and  fluctu- 
ating at  others ;  they  are  more  largely  and  deeply 
lobulated,  fungate  once  in  every  seven  cases,  and  dis- 
charge by  the  nipple  in  an  equal  proportion  of  in- 
stances. Their  growth  is,  moreover,  sudden  and 
rapid  after  having  remained  stationary,  or  advanced 
slowly,  for  several  years. 


CHAPTER    YI. 

SARCOMA. 

Of  the  neoplasms  of  the  breast  there  is  none 
about  which  so  little  was  known  up  to  a  compara- 
tively recent  period  as  that  denominated  sarcoma. 
Indeed,  even  at  the  present  day,  it  is  included 
among  other  growths  by  practical  surgeons.  The 
term  itself  has  no  histological  significance,  having 
been  employed  by  Abernethy  to  designate  a  tumor 
"  having  a  firm  and  fleshy  feel " ;  but  it  is  now  used 
to  indicate  a  new  formation,  which  has  its  physiologi- 
cal type  in  embryonic  tissue,  and  is  composed  of  the 
undeveloped  cells  of  the  connective  tissue  series, 
separated  by  intercellular  substance.  From  the  ex- 
cessive preponderance  and  grouping  of  the  cells, 
which  endow  it  with  its  peculiar  characters,  and  from 
their  indisposition  to  develop  into  higher  tissues,  they 
constitute  a  structure  which  is  unlike  any  mature  tis- 
sue, and  may,  therefore,  be  regarded  as  an  atypical 
connective  tissue  production,  just  as  carcinoma  is  an 
atypical  epithelial  growth. 

The  histogenesis  of  sarcoma  is  very  simple.  In 
consequence  of  the  irritation  to  which  they  are  sub- 
jected, the  endothelial  cells  of  the  connective  tissue 
stroma  of  the  mamma  proliferate,  and  they,  along 
with  the  emigrant  colorless  blood  corpuscles,  the  fat 
5 


66  SARCOMA. 

cells,  and,  it  may  be,  the  endothelmm  of  the  smaller 
vessels,  are  converted  into  an  embryonic  mass ;  this 
mass  foiTQs  the  indifferent,  small-celled,  or  granu- 
lation tissue,  which  constitutes  the  starting-point  of 
nearly  all  neoplasms.  In  addition  to  these  nutritive 
disturbances,  there  is  a  new  growth  of  vessels,  so 
that  there  results  a  structure  similar  to  that  of  granu- 
lations, out  of  which,  through  changes  in  the  mor- 
phology of  the  cells  and  the  character  of  the  intercel- 
lular substance,  the  varieties  of  sarcoma  originate. 
Hence,  it  will  be  seen,  that  the  textural  modifications 
are  the  same,  primarily,  as  those  witnessed  in  ordi- 
nary granulation  tissue. 

The  varieties  of  sarcoma  are  determined  by  the 
prevailing  fonn  of  the  cells,  while  certain  subdivis- 
ions are  constituted  by  the  nature  of  the  intercellular 
substance,  which  may  be  hyaline,  granular,  fibrillated, 
lymphoid,  or  alveolar,  and  by  various  transformations, 
as  the  myxomatous,  fatty,  telangiectatic,  cystoid,  and 
calcareous,  the  latter  of  which  mil  be  considered 
under  the  degenerations  to  which  these  tumors  are 
liable.  In  accordance  with  the  dimensions  of  the 
cells,  they  are,  moreover,  separated  into  the  small- 
celled  and  the  large-celled. 

1.  Eound-Celled  Sarcoma.  —  The  structure  of 
round-celled  sarcoma,  which  is  equivalent  to  the  em- 
bryoplastic  tumor  of  Robin,  the  medullary  sarcoma 
of  Miiller,  the  granulation  sarcoma  of  Billroth,  and 
the  encephaloid  sarcoma  of  Comil  and  Ranvier,  is 
usually  composed  mainly,  as  is  seen  in  fig.  7,'  of  fra- 

'  From  a  section  of  a  tumor,  of  twelve  months'  duration,  which  had  invaded 
two-thirds  of  the  right  mamma  of  a  spinster  forty-two  years  of  oge.  Its  con- 
sistence was  firm  and  elastic,  except  at  a  spot  as  large  as,  a  silver  dollar,  where 


VARIETIES. 


67 


gile  spherical  cells,  of  tlie  size  of  Ijonpli  corpuscles, 
and  provided,  as  a  rule,  with  a  single  round  or  ovoid 
nucleus,  whicli  is  large  vrhen  compared  ^vitli  the  pro- 


FiG.  T. 


3  oa  r^J§t 


Small  Rodjjd-Cellfd  Sarcoxta. — «,  Transverse  section  of  a  duct,  partially  filled 
with  hyperplastic  epithelium,  e,  and  limited  by  its  raembrana  propria,  6,  the 
endothelial  cells  of  which  are  very  apparent,  c  c,  and  d,  Transverse  sections 
of  vessels  with  embryonic  walls.    /,  Longitudinal  cut  of  a  vessel. 

toplasm  of  the  cell,  and  held  together  by  a  scanty, 
soft,  amorphous,  dimly  granular,  or  finely  fibrillated 
intercellular  substance.  Numerous  large  but  delicate 
vessels  pervade  the  tissue,  and  are  very  liable  to  rup- 
ture. From  these  general  features  there  are  some 
histological  variations  whereby  certain  subdivisions 
are  constituted. 

a.  Lym'phoid  Sarcoma. — Wheu  the  intercellular 
substance  forms  a  delicate  reticulum  of  hyaline  fibres, 
the  meshes  of  which  are  occupied  by  a  single  cell,  as 

it  was  somewhat  soft,  and  the  skin  was  tense  and  livid.  The  nipple  and  axillary 
glands  were  normal,  and  there  were  no  adhesions  to  the  chest.  The  cut  surface 
of  the  growth  had  a  translucent,  grayish  look  ;  was  interspersed,  here  and  there, 
with  points  of  extravasated  blood ;  and  was  the  seat  of  two  softening  cysts  be- 
neath the  discolored  integument.  Despite  the  fact  that  I  removed  the  entire 
breast,  with  its  coverings  and  the  pectoral  fascia,  recurrence  ensued  in  two 
months,  or  before  cicatrization  was  completed. 


68  SARCOMA. 


in  fig.  8/  so  that  tlie  structure  resembles  the  cyto- 
genous  or  adenoid  tissue  of  the  lymph  follicles,  the  tu- 
mor is  known  as  lymphoid  or  lymphadenoid  sarcoma. 


Coo 


Reticulated  Tissue  of  a  Lymphoid  Sarcoma,  pektaded,  here  and  there,  bt 
Bands  of  Vascular,  Delicate,  Wavy,  Fibrous  Tissoe. — The  meshea  are 
occupied  by  cells  which  are  shrunken  from  the  hardening  process  to  which 
the  tumor  was  subjected.  With  the  exception  of  a  few  dilated  ducts,  the 
glandular  elements  had  disappeared. 

/3.  Alveolar  Sarcoma, — A  still  greater  departure 
from  the  ordinary  t}^e  is  occasionally  met  with,  the 
cells  beino;  contained  within  the  alveoli  of  a  connec- 
tive  tissue  meshwork,  through  which  it  bears  a  close 
resemblance  to  carcinoma,  but  from  which  it  differs, 
first,  by  the  cells  being  intimately  connected  with  the 
walls  of  the  alveoli  or  the  vessels  which  form  the 
alveoli;  and,  secondly,  by  the  existence  of  a  reticu- 
lated intercellular  substance,  like  that  seen  in  the 
preceding  variety.  In  other  words,  the  stroma  and 
cells  are  intimately  interwoven  into  a  single  tissue; 
while,  in  carcinoma,  they  are  easily  separable  into 
two  distinct  tissues." 

'  From  a  lobulated,  elastic,  mobile  growth,  of  three  months'  duration,  which 
I  enucleated  from  the  upper  and  outer  border  of  the  left  mamma  of  a  single 
woman  twenty-two  years  of  age.  It  had  a  diameter  of  an  inch  and  a  half,  and 
its  tolerably  firm  section  had  a  rosaceous-gray  tint. 

*  Compare  with  my  paper  on  Sarcoma  of  the  Long  Bones,  Amer.  Jour.  Med. 
Sciences,  October,  1879,  p.  34*7. 


VARIETIES. 


69 


2.  Spestdle-Celled  Sakcoma. — Spindle-celled  sar- 
coma, which  is  synonymous  with  the  fasciculated  car- 
cinoma of  Miiller,  the  albuminous  sarcoma  of  Gluo-e, 
the  fibronucleated  tumor  of  Bennett,  the  recurrent 
fibroid  tumor  of  Paget,  the  fibroplastic  tumor  of  Le- 
bert,  the  plasmoma  of  Follin,  and  the  fasciculated 
sarcoma  of  Cornil  and  Ranvier,  has  its  pathological 
prototype  in  recent  cicatrices,  and  is  made  up  of  fusi- 


FiG.  9. 


Small  Spindle-Celled  Sarcoma. — Showing  the  spindlc-celkd  tissue  surrounding 
a  longitudinal  section  of  a  dilated  duct,  with  its  terminal  acini,  which  are 
lined  by  low  columnar  epithelium.  One  of  the  acini  is  filled  with  hyper- 
plastic epithelium. 


form  cells,  which  vary  greatly  in  size,  as  is  shown  in 
figs.  9  *  and  10,"  although  they  are  usually  small,  that 
is  to  say,  short  and  narrow,  and  provided  with  a  sin- 
gle ovoid  nucleus.  The  intercellular  substance  is 
generally  very  scanty,  and  the  tapering  extremities 

'  From  a  section  of  the  tumor  delineated  in  fig.  12. 

*  From  the  margin  of  a  section  of  a  tumor,  of  less  than  two  months'  standing, 
removed,  along  with  the  entire  breast,  by  Dr.  C.  B.  Nancrede,  from  a  married  and 
prolific  woman  thirty-five  years  of  age.  The  skin  was  discolored,  and  false 
fluctuation  was  so  distinct  that  it  had  been  punctured  a  few  days  previously 
under  the  supposition  that  it  was  an  abscess.  The  tissue  was  almost  diflfluent 
and  highly  yascular. 


70  SARCOMA. 

of  one  cell  are  received  between  the  bellies  of  two 
contiguous  cells,  forming  a  tissue  wliich  is  composed 
of  bands   or  fasciculi   of  closely   aggregated   cells; 

Fig.  10. 


Large  Spindle-Celled  Sarcoma,  a  a  a,  Transverse  sections  of  spindle  cells. 
The  cells  are  all  highly  granular,  and  vary  in  form  without  departing  mate- 
rially from  the  usual  shape. 

these  cells  interlace  in  every  direction,  so  that  a  sec- 
tion discloses  longitudinal,  oblique,  and  transverse 
bundles,  the  last  of  which  may  be  mistaken  for 
round  or  oval  cells.. 

3.  Giant-Celled  Saecoma. — Myeloid,  or  giant- 
celled,  sarcoma,  is  composed,  as  is  seen  in  fig.  11,*  of 
large  multinucleated  elements,  imbedded  usually  in  a 
stroma  of  spindle  and  round  cells,  with  the  interven- 
tion of  little,  if  any,  visible  intercellular  substance. 
The  tissue  has,  therefore,  an  apparently  alveolar  con- 
struction, which  is  the  more  striking  when  the  cells 
have  undergone  mucoid  softening,  or  are  obscured  by 
advanced  fatty  changes. 

Apart  from  distention  of  the  ducts,  w^hich  gives 
rise  to  cystic  sarcoma,  the  glandular  structure  of  the 
mamma  persists,  to  a  greater  or  a  lesser  extent,  in  only 

'  From  a  section  of  a  tumor  of  the  head  of  the  tibia,  which  I  have  recorded 
in  the  Amer.  Jour.  Med.  Sciences,  Julj)  1879,  p.  29.  The  figure  is  introduced 
here  for  purposes  of  comparison. 


VARIETIES.  Yl 

about  one-tliii'd  of  all  specimens  of  sarcoma,  and  tlien 
principally  in  tlie  spindle-celled  growths  whicli  are 
denominated  adenoid  sarcomata,  and  wMcli  rarely  at- 

PlG.   11. 


Giant-Celled  Sarcoma. — Showing  the  characteristic  multinucleated  elements 
contained  in  a  stroma  of  spindle  cells,  transverse  sections  of  which  are  seen 
at  the  upper  corner  to  the  right  of  the  figure. 

tain  a  considerable  volume  before  tbeir  removal.  In 
none  of  the  specimens  which  I  have  examined  did  the 
endothelial  cells  of  the  membrana  propria  participate 
in  the  proliferation,  so  that  that  structure  remained 
intact,  although  it  may  be  thickened,  or,  as  more  fre- 
quently happens,  attenuated.  Labbe  and  Coyne,' 
however,  state  that  it  may  disappear  entirely,  and 
that  the  epithelial  cells  then  rest  upon  the  spindle 
elements  of  the  tumor;  but  this  statement  appears 
to  me  to  have  arisen  from  a  misinterpretation  of  the 
picture,  since  in  the  normal  state  the  innermost  boun- 
dary of  the  proper  membrane  consists  of  a  subepi- 
thelial layer  of  parallel  spindle  cells,  which  always 
enlarge  when  the  acini  or  ducts  are  dilated  as  the 
result  of  the  morbid  changes  going  on  around  them. 

>  Op.  ciL,  p.  291. 


T2  SARCOMA. 

Mucoid  transformation  of  tlie  matrix,  fatty  infil- 
tration of  tlie  cells,  increased  vascularization,  tlie  depo- 
sition of  tlie  earthy  salts  in  tlie  intercellular  substance, 
and  the  persistence  of  the  remains  of  the  preexisting 
connective  tissue  of  the  mamma,  constitute  the  sub- 
divisions of  sarcoma  known  as  the  myxomatous, 
lipomatous,  telangiectatic,  calcifying,  and  fibrous,  so 
that  these  terms  may  be  employed  as  j)refixes  to 
denote  the  nature  of  the  changes  that  have  ensued, 
or  desi2:nate  the  existence  of  certain  subordinate  tis- 
sues.  The  term  cystic  is  employed  to  indicate  dila- 
tation of  the  ducts,  while  cystoid  is  prefixed  to  the 
tumor  when  it  is  the  seat  of  softening  cysts. 

Of  the  varieties  of  sarcoma  the  spindle-celled  is 
by  far  the  most  common,'  as  it  constituted  eleven  of 
the  sixteen  cases '  that  have  come  under  my  personal 
obsen^ation,  and  was  met  with  in  forty-five  of  the 
sixty  examples  that  I  have  collated  to  illustrate  the 
pathology  of  the  affection.  Lancereaux '  records  an 
example  of  giant-celled  tumor,  and  myeloid  elements 
were  present  in  considerable  numbers  in  a  specimen 
of  recurrent  round-celled  sarcoma  which  I  exhibited 
at  the  Pathological  Society,*  and  they  were  also  found 
in  a  recurrent  spindle-celled  growth  by  Haward."  Of 
the  subdivisions  the  most  common  is  the  cystic,  as 

'  Virchow,  op.  cit.,  p.  355,  and  Rindfleisch,  op.  cit,  p.  545,  regard  the  round- 
celled  as  being  the  most  common. 

*  Of  the  eleven  spindle-ccllcd,  five  were  small,  firm,  adenoid  growths ;  one 
was  a  telangiectatic  and  myxomatous,  and  one  a  myxomatous  medullary  sar- 
coma ;  four  were  firm  cystic,  and  in  one  of  these  the  cysts  were  filled  with  vegeta- 
tions. Of  the  five  round-celled,  one  was  lymphoid ;  one  was  a  myxomatous  cystic 
medullary  growth  ;  two  were  vegetating,  and  one  of  these  was  medullary ;  and 
one  was  a  cystoid  medullary  tumor. 

^  Bull,  de  la  Soc.  Anat.,  ser.  2,  t,  v,  p.  292, 

*  Phila.  Med.  Times,  vol.  ix,  p.  883. 

*  Trans.  Clin.  Soc.  of  London,  vol.  vii,  p.  106. 


CONSISTENCE.  73 

nearly  six-tentlis  of  all  sarcomata  of  tlie  breast  are  of 
that  nature.  Next  in  point  of  frequency  are  the 
myxomatous  and  telangiectatic ;  after  which  come 
the  fibrous,  cystoid,  and  calcifying.  The  lymphoid 
is  so  uncommon  that  I  am  not  aware  of  any  other 
example  than  my  own.  The  alveolar,  as  far  as  I 
know,  has  been  only  seen  as  a  recurrent  growth, 
while  the  melanotic  is  unheard  of. 

Like  the  other  encapsuled  neoplasms  of  the  mam- 
ma, circumscribed  sarcomata  are  ovoid,  rounded,  or 
spherical,  lobed  or  bossed,  and  seldom  smooth  and 
uniform,  the  surface  irregularities  being  most  marked 
in  the  cystic  variety.  As  a  rale  they  are  unattached 
to  the  gland,  but  push  it  aside,  compress,  and  flatten 
it,  or  cause  it  to  atrophy,  although  they  are,  in  rare 
instances,  united  to  it  by  a  pedicle.  Their  consistence 
varies  with  their  minute  structure  and  degenerations, 
the  pure  spindle-celled  tumors  being  firm,  like  fibro- 
mata, while  the  round-celled  are  soft  and  elastic.  The 
former,  however,  are  soft  in  about  one-third  of  all 
examples,  when  they  will  be  found  to  be  composed 
of  small  fusiform  cells,  or  to  have  undergone  myxo- 
matous or  fatty  transformation,  or  to  be  the  seat  of 
interstitial  hemorrhao:e.  The  latter  are  hard  in  about 
one-fourth  of  all  cases,  when  they  will  usually  be 
found  to  be  rich  in  fibrous  intercellular  substance. 
In  one  of  the  best  illustrations  of  round-celled  tumors 
that  I  have  ever  seen,  the  tissue  was  dense,  so  that 
they  are  by  no  means  synonymous  with  soft,  medul- 
lary, or  encephaloid  sarcomata,  although  they  are  usu- 
ally much  softer  than  the  spindle-celled  variety,  since 
they  are  peculiarly  rich  in  cells  and  bloodvessels,  and 
since  their  intercellular  substance  is  usually  mucoid. 


74  SARCOMA. 

The  spindle-celled  growths  sometimes  creak  or  cry 
under  the  knife,  in  which  event  they  come  tinder  the 
category  of  fibrous  sarcomata,  from  the  large  admix- 
ture of  fibrous  tissue.  Their  consistence  varies,  more- 
over, with  their  stage  of  development.  If  they  are 
solid,  it  is  entirely  or  almost  uniform;  while  they 
are  soft  and  elastic,  or  soft  and  fluctuating  at  some 
points,  and  especially  at  the  larger  bosses,  and  hard 
at  others,  when  they  are  the  seat  of  cysts  occupied 
by  fluid,  or  solid  contents,  or  by  both.  In  about  one- 
fourth  of  the  cystic  growths,  however,  the  tumor  is 
firm  throughout,  in  consequence  of  the  cysts  being  so 
deeply  seated  as  to  elude  detection  by  manipulation. 
On  section  the  spindle-celled  tumors  are  usually 
smooth,  succulent,  and  glistening,  and  of  a  white  or 
grayish-white  color,  particularly  if  they  are  poor 
in  vessels,  the  tint  being  rosaceous-white  or  rosace- 
ous-gray when  their  vascular  supply  is  larger.  The 
round-celled  tumors,  on  the  other  hand,  are  rarely 
pure  white,  but,  from  their  relatively  greater  vascu- 
larity, reddish-white,  reddish-yellow,  or  reddish-gray, 
the  hue  being  not  infrequently  comparable  to  that  of 
the  foetal  brain.  When  they  are  highly  vascular  the 
rosaceous  tint  is  very  marked,  or  they  are  pervaded 
by  macroscopic  vessels ;  or  dotted  with  minute  spots 
of  ecchymosis,  or  patches  or  streaks  of  bright  red  or 
brown,  or  various  intermediate  shades  of  pigmenta- 
tion. In  not  a  few  instances  the  soft  brain-like  tissue 
is  so  extensively  interspersed  with  clots  of  blood,  and 
with  cysts  containing  blood,  that  the  tenn  hematoid 
sarcoma  is  not  inappropriately  applied  to  them,  or  the 
term  fungus  hematodes  when  they  protrude  through 
the  skin.     A  pronounced  yellomsh  color  indicates 


COLOR.  75 

fatty  metamorpliosis,  wliicli  may  pervade  almost  the 
entire  tumor,  or  be  confined  to  limited  areas  or  to  the 
vegetations  alone,  while  the  remainder  is  white  or 
gray,  thereby  imparting  to  it  a  mottled  aspect.  A 
yellowish  tint  also  denotes  myxomatous  changes,  so 
that,  as  in  the  former  instance,  the  mass  of  the  growth 
may  be  white  or  rosaceous-white  or  rosaceous-gray, 
and  the  vegetations  be  yellow.  On  the  whole,  how- 
ever, gelatinous  spots  dotting  the  surface  of  the  sec- 
tion are  the  best  characteristic  of  this  change.  Now 
and  then,  or  when  great  vascularity  and  the  fatty 
and  myxomatous  degenerations  are  combined,  there 
will  be  areas  of  yellow  and  red,  and  spots  of  brown 
pigmentation,  along  with  gelatinous  dots.  In  point 
of  fact  the  color  is  so  variable  that  it  is  extremely 
difficult  to  give  an  intelligible  description  of  it.  The 
cut  surfaces  of  many  of  the  largest  specimens  have 
also  a  lobed  appearance  from  the  close  packing  of 
the  vegetations  in  the  enlarged  ducts  which  play  the 
part  of  capsules. 

The  gross  characters  of  the  smaller  tumors,  which 
correspond  to  the  adenoid  sarcomata  of  Billroth,  and 
which  do  not  grow  larger  than  a  walnut  in  seven  or 
eight  months,  are  worthy  of  notice,  as  they  differ 
from  fibromata  of  the  same  dimensions  in  several  par- 
ticulars that  are  useful  in  establishing  a  differential 
diagnosis.  Thus,  of  the  five  specimens  of  spindle- 
celled  growths  which  I  have  extirpated,  all  were 
lobulated,  firm,  elastic,  adherent  to  the  gland,  grayish- 
white  in  color,  and  tough  on  section.  The  fibromata, 
on  the  other  hand,  were  hard,  merely  nodular,  less 
adherent  to  the  mamma,  white,  and  more  compact  and 
tough  on  section.     Under  the  microscope,  the  glan- 


Y6  SARCOMA. 

dular   elements  were  undero-oino;   obliteration   to   a 
greater  extent  in  the  former  than  in  the  latter. 

Inflammation  and  suppuration  of  mammary  sar- 
coma are  infrequent,  but  ulceration  of  the  overlying 
tissues  and  fungous  protrusion  are  so  common  that 
they  occurred  in  fifteen  of  the  sixty  cases  that  I  have 
collated,  a  proportion  which  is  four  times  greater 
than  is  met  with  in  fibroma.  As  is  witnessed  in  the 
latter  tumor,  the  ulceration  appears  to  be  the  result 
rather  of  inflammation  and  gangrene  of  the  attenu- 
ated skin  than  of  its  infiltration  by  sarcomatous 
cells ;  but  in  one  case  it  depended  upon  exploratory 
puncture.  Fungous  protrusion  almost  invariably  fol- 
lows the  perforation  of  the  integuments,  although  in 
a  remarkable  instance  recorded  by  Ashhurst,'  the 
recurrent  growth  of  which  I  exhibited  at  the  Patho- 
logical Society,  the  ulcer  subsequently  healed.  The 
protruding  mass  varies  in  size  from  a  hazel-nut  to 
three,  four,  and  even  five  inches  in  diameter,  and 
exhales  a  sanguinolent  and  fetid  discharge,  which 
may  become  more  or  less  purulent  from  inflammation 
induced  by  exposure  and  friction.  It  is  not,  how- 
ever, very  liable  to  free  hemorrhage  or  sloughing,  as 
the  former  accident  was  observed  in  only  three  in- 
stances, and  the  latter  in  one.  The  ulcer  itself  is 
usually  circular,  and  the  surrounding  skin  is  not 
only,  as  a  rule,  free  from  discoloration,  but  it  is  also 
unattached  to  the  fungus,  and  everted,  or  rather  ele- 
vated, on  its  sides.  Now  and  then  there  are  several 
ulcers,  separated  by  bridges  of  sound  tissue.  From 
a  diagnostic  standpoint,  it  is  worthy  of  notice  that 
ulceration  occurred  in  three  out  of  twenty-five,  or 

^  Trans.  Path.  Soc.  Phila.,  vol.  v,  p.  230. . 


METAMORPHOSES.  Y7 

12  per  cent.,  of  solid  sarcomata,  against  twelve  out 
of  thirty-five,  or  34  per  cent.,  of  cystic  sarcomata,  and 
that  it  was  rather  more  frequent  in  the  round-celled 
than  in  the  spindle-celled  growths. 

The  metamorphoses  of  sarcomata  are  the  myxoma- 
tous, fatty,  telangiectatic,  cystoid,  and  calcareous. 
They  usually  begin  in  their  centre,  which  may  be 
quite  soft  and  broken  down,  while  the  periphery  is 
unchanged.  Myxomatous  degeneration  is  met  with 
in  18*5  per  cent,  of  all  cases,  being  most  common  in 
the  spindle-celled  and  cystic,  and,  along  with  fatty 
changes,  is  the  most  frequent  cause  of  the  large  inter- 
stitial hemorrhao;es  to  which  these  tumors  are  liable. 
Although  sarcomata  are  more  vascular  than  the  other 
neoplasms  of  the  breast,  they  are  only  excessively  so 
in  18*5  per  cent,  of  all  cases,  in  which  event  they  are 
liable  to  be  converted,  in  great  part,  into  a  dark-red, 
grumous,  pultaceous  material ;  and  the  dilated  ducts 
often  contain  sanguinolent  fluid,  or  even  pure  blood. 
In  such  cases  minute  examination  discloses  very  nu- 
merous vessels,  the  adventitia  of  which  is  infiltrated 
with  found  cells  undergoing  fatty  degeneration, 
through  which  they  lose  their  power  of  resistance, 
become  varicose  and  dilated,  finally  give  way,  and 
emit  a  large  quantity  of  their  contents.  Cystoid 
changes,  due  either  to  fatty  or  mucoid  transforma- 
tion of  the  glandular  epithelium,  or  to  fatty  changes 
of  the  sarcomatous  cells,  are  met  Vvdth  in  about  10 
per  cent,  of  all  instances,  the  former  being  the  more 
common,  and  almost  peculiar  to  solid  sarcomata. 
These  glandular  and  softening  cysts  must'  not,  how- 
ever, be  confounded  with  the  cysts  which  arise  fi*om 
ectasia  of  the  ducts,  and  which  constitute  true  cystic 


Y8  SARCOMA. 

sarcoma.  Tlie  contents  of  tlie  false  cysts  may  be 
yellowish,  lactescent,  mucoid,  or  gelatinous.  The 
cavities  are  rarely  of  large  dimensions,  although  they 
may  give  rise  to  extensive  areas  of  diffluent,  broken- 
down  tissue,  and  may  be  associated  wdth  extravasa- 
tions of  blood.  Calcareous  degeneration  is  less  com- 
moli  than  in  fibroma,  as  it  was  noticed  in  only  two 
instances,  or  in  3'3  per  cent.,  of  all  cases,  in  one  of 
which  cretaceous  plates  were  found  in  the  walls  of  a 
duct  cyst,  and  in  the  second  of  which  the  mineral 
salts  were  interspersed  throughout  a  limited  portion 
of  the  tumor.  Billroth '  refers  to  a  large  cystic  sar- 
coma which  contained  plates  of  bone,  but  ossification 
was  not  met  with  in  the  cases  that  I  have  collated, 
nor  were  any  characterized  by  the  presence  of  carti- 
lage, although  Coats"  describes  a  specimen  of  sar- 
comatous chondro-fibroma. 

Sarcomata  of  the  breast  are  generally  solitaiy,  since 
I  find  of  sixty  cases  that  only  six  were  multiple,  several 
growths  existing  in  the  same  gland  in  five,  and  in 
both  in  one.  Their  most  common  seat  is  beneath,  or 
in  the  vicinity  of,  the  nipple,  and,  when  they  arise 
from  the  circumference  of  the  organ,  they  are  usually 
found  at  its  upper  and  inner  side.  When  of  central 
origin  they  are,  for  the  most  part,  cystic ;  while 
they  are  usually  solid  when  they  start  fi'om  outly- 
ing lobules.  In  either  event  they  evince  a  marked 
disposition  to  extend  beyond  the  limit  of  their  cap- 
sules, those  of  central  origin  gradually  invading  the 
entire  gland,  and  the  surrounding  soft  parts,  while 
the  peripheral  ones  not  only  infect  the  latter  struc- 

'  VircJiow^s  Archil',  Bd.  xviii,  p.  59. 

2  Glasgow  lied.  Jour.,  Nov.,  ISIl,  p.  45.   > 


ETIOLOGY.  79 

tures,  but  also  finally  implicate  tlie  entire  breast.  As 
a  rule  they  give  rise  to  broadly  based  hemisplierical 
tumors,  but  they  are  now  and  then  pedunculated. 

They  occur  as  early  as  the  fourteenth  and  as  late 
as  the  sixty-fourth  year,  the  average  age  of  their  first 
observation  being  35'5  years.     Of  the  60  cases, 

8  appeared  between  10  and  20  years. 
10    "      "   20  "  30   " 
23    "       "    30  "  40   " 
13    "       "    40  "  50   " 

4    "       "    50  "  60   " 

2    "      "   60  "  70   " 

Of  the  entire  number  only  one,  or  1'66  per  cent., 
occurred  before  the  sixteenth  year,  or  during  the 
developmental  state  of  the  mamma ;  40,  or  66*66  per 
cent.,  appeared  between  the  sixteenth  and  fortieth 
years,  or  at  a  period  when  the  breast  and  genitalia 
are  functionally  most  active ;  and  19,  or  31*66  per 
cent.,  after  the  fortieth  year,  or  during  the  period  of 
their  functional  decline.  Spindle-celled  tumors  de- 
velop earlier  in  life  than  the  round-celled,  since  the 
average  age  at  which  forty-five  examples  of  the  for- 
mer were  noticed  was  32*6  years,  against  42*4  years 
for  fifteen  cases  of  the  latter.  Unlike  cystic  and 
solid  fibromata,  cystic  sarcomata  appear  at  an  earlier 
age  than  solid  sarcomata,  the  average  for  thirty -five 
instances  of  the  cystic  being  33*7  years,  against  37 
years  for  twenty-five  examples  of  the  solid  variety. 
Hence  it  may  be  said  that,  while  sarcomata  and  fibro- 
mata are  both  outgrowths  of  the  active  mamma,  spin- 
dle-celled and  cystic  sarcomata  are  metaplasias  of  the 
functionally  perfect  mamma,  and  round-celled  and 
solid  sarcomata  are  metaplasias  of  the  declining  gland. 


80  SARCOMA. 

In  point  of  fact,  a  sarcoma  occurring  before  tlie  age 
of  twenty  is  liable  to  be  a  spindle-celled  tumor  in 
seven-eightlis  of  all  cases. 

Fifteen  of  the  patients  were  single  and  twenty- 
six  were  married  when  the  tumor  was  first  noticed, 
while  the  social  condition  is  not  noted  in  the  re- 
mainder. Of  the  married  women  sixteen  were  mul- 
tiparous,  three  had  one  child,  and  four  were  barren ; 
while  the  question  of  children  is  not  stated  in  three. 
In  one  case  the  disease  showed  itself  during  preg- 
nancy, in  four  soon  after  parturition,  and  in  one  three 
years  after  the  menopause.  Of  twenty-four  subjects 
in  which  the  menstrual  function  is  recorded,  all  were 
regular,  and  the  youngest  patient,  a  girl  of  fourteen, 
was  menstruating.  In  only  eight  instances,  or  one  in 
every  seven  and  a  half,  was  injury  assigned  as  the 
cause  of  the  tumor ;  in  one  it  developed  at  the  site  of 
an  abscess ;  in  one  it  was  preceded  by  psoriasis  of 
the  nipple ;  while  in  none  was  it  inherited.  These 
facts  show  that  the  etiology  of  sarcomata  is  most  ob- 
scure, since  their  development  is  rarely  traceable  to 
injury  or  disease,  and  is  not  influenced  by  hereditary 
predisposition,  while  the  social  state  and  menstrual 
irregularities  or  arrest  are  surely  unimportant  agents 
in  their  production. 

The  increase  of  sarcomata  is  more  rapid  than  that 
of  fibromata  and  myxomata,  but  it  is  liable  to  great 
diversity,  being  independent  of  the  age  of  the  sub- 
ject, and  influenced  by  their  structure,  by  their  de- 
generations, and  by  the  absence  or  presence  of  cysts. 
Of  the  solid  sarcomata  I  have  met  with  six  examples 
which  varied  from  one  to  two  inches  in  diameter  in 
five,  six,  seven,  and  eight  months ;  and^  even  at  the 


GROWTH.  81 

end  of  two  or  three  years,  they  may  not  be  larger 
than  an  apricot '  or  a  turkey's  egg^^  although  they 
may,  in  their  pure  state,  attain  the  volume  of  an 
adult  head  in  four  months,"  or  a  circumference  of 
twenty-five  inches  and  a  weight  of  four  pounds  and 
two-thirds  in  nine  months."  When  they  are  the 
seat  of  myxomatous  degeneration  or  of  softening 
cysts,  they  may  weigh  four  pounds  and  twelve 
ounces/  or  measure  twenty-three  inches  in  circumfer- 
ence and  weigh  six  pounds,  in  four  months/  Of  the 
cystic,  as  of  the  solid,  variety,  I  have  seen  examples 
in  which  it  did  not  exceed  a  diameter  of  two  inches 
in  five  and  eight  months;  while  it  is  rarely  larger 
than  a  fist  in  one  year.  In  exceptional  instances, 
however,  it  may  attain  a  weight  of  upward  of  ten 
pounds  in  the  same  number  of  months,"  or  a  circum- 
ference of  thirty-one  inches  and  a  weight  of  twelve 
pounds  in  one  year.*  As  an  evidence  of  its  un- 
equal rate  of  progress,  we  may  state  that  it  may  re- 
quire eighteen  months '  or  five  years '"  to  reach  the 
volume  of  a  foetal  head,  or  six  years "  or  fifteen 
years  ''^  to  attain  the  size  of  an  adult  head. 

Like  the  cystic  fibromata,  sarcomata  may  remain 
stationary  and  of  small  dimensions  for  a  long  time, 

'  Revcrdin,  BuU.  de  la  Soc.  Anaf.,  t.  xlii,  p.  708,  and  t.  xliv,  p.  285. 

'  Zambianchi,  Toid.,  t.  xlvi,  p.  314. 

3  Billroth,  Chir.  Klivik,  Wien,  lS69-"70,  p.  142. 

*  Bryant,  Trans.  Path.  Soc.  London,  vol.  xix,  p.  38Y. 

*  Bennett,  Cancerous  and  Cancroid  Growtlis,  pp.  12  and  256. 
^  Hcwson,  Gross's  S,i/sfem  of  Surgerv,  5th  ed.,  vol.  ii,  p.  985. 
'  GUick,  Lavgenheck''s  Archiv,  Bd.  viii,  Jahresbericht,  p.  599. 
8  Pitha,  Md.,  p.  599. 

'  Hubert,  Bull,  de  la  Soc.  Anat.,  t.  xlviii,  p.  690. 
'"  Revcrdin,  Ibid.,  t.  xliv,  p.  281. 
"  Hubert,  Ibid.,  t  xlviii,  p.  389. 
"  Berbeze,  Ibid.,  t.  xli,  p.  94. 
6 


82  SARCOMA. 

when,  wittout  obvious  cause,  tliey  suddenly  begin  to 
increase,  so  tbat  a  nodule  tliat  lias  required  fifteen 
years  to  attain  tlie  volume  of  a  walnut  reaches  that 
of  a  double  fist  in  three  months  ; '  or  one  that  has  been 
quiescent  and  of  the  size  of  a  walnut  for  twenty-five 
years,  suddenly  begins  to  grow,  and  measures  eighteen 
inches  transversely  by  fourteen  inches  and  a  half  ver- 
tically in  three  years ; '  or  one  that  has  been  a  year 
and  a  half  in  acquiring  the  volume  of  an  e^o^  grows 
to  a  circumference  of  twenty-six  inches,  and  a  weight 
of  seven  pounds  in  an  additional  six  months/  In 
such  cases  rapid  accumulation  of  fluid  and  solid  con- 
tents in  the  dilated  ducts  may  be  looked  for,  with  the 
addition,  probably,  of  myxomatous  changes  and  inter- 
stitial hemorrhage,  as  in  the  case  from  which  fig.  12 
was  taken.  Under  similar  circumstances  their  prog- 
ress may  be  interrupted,  of  which  a  notable  example 
is  recorded  by  Robin,*  in  which  a  vegetating  myxo- 
matous spindle-celled  tumor  remained  of  the  size  of  a 
hazel-nut  for  six  years,  when  it  grew  continuously  for 
four  years,  and  reached  the  volume  of  a  fist,  and  then 
doubled  its  size  in  three  years  and  a  half,  and  during 
the  last  six  months,  or  fourteen  years  from  its  first 
appearance,  attained  a  weight  of  nine  pounds.  Inter- 
mission of  growth  is  not  infrequent  in  sarcoma,  and  is 
of  diagnostic  value  when  compared  with  the  progress 
of  other  neoplasms  of  the  breast.  As  occurs  in 
fibroma,  continuous  growth  rather  indicates  freedom 
from  cysts  and  vegetations,  while  sudden  and  rapid 

'  Marignac,  Bull,  de  la  Soc.  Anat.,  t.  lii,  p.  428. 

'  Anderson,  Trans.  Path.  Soc.  Lond.,  vol.  xxiii,  p.  254. 

*  Marchand,  Gaz.  dts  Hopitaux.,  No.  51,  1869,  p.  196. 

*  Journal  de  VAnat.  et  de  Fhp.,  t.  x,  p.  195,  and  Bull,  de  la  Soc.  Anat.,  t. 
xlviii,  p.  817, 


OROWTE. 


83 


increase  points  to  fluid  accumulation  and  intracana- 


licular  vegetations. 


The  growth  of  sarcomata  might  naturally  be  ex- 
pected to  be  connected  with  menstruation,  pregnancy, 


Tig.  12.1 


Myxomatous  and  Telangiectatic  Cystic  Small  Spindle-Celled  Sakcoma. 


or  lactation,  or  with   conditions  which   render  the 
mammary  gland  more  vascular ;  but  the  influence  of 

'  Myxomatous,  telangiectatic,  cystic,  spindle-celled  sarcoma,  the  minute  fea- 
tures of  which  arc  represented  in  fig.  9.  A  young  and  single  lady,  twenty-four 
years  of  age,  first  noticed,  seven  years  previously,  or  a  few  months  after  the 
establishment  of  menstruation,  a  lump,  as  large  as  a  hickory-nut,  just  above  and 


84  SARCOMA. 

an  increased  flow  of  blood  to  the  organ,  whicli  Las 
been  assumed  by  certain  authors,  is  not  confirmed  by 
an  analysis  of  the  cases  that  I  have  collected.  Thus, 
in  only  two  examples  *  was  an  increase  in  bulk  wit- 
nessed at  the  menstrual  period,  while  in  one  the 
tumor  became  smaller/  and  in  two  the  rapid  growth 
began  at  the  menopause/ 

From  these  considerations  it  follows  that,  while 
sarcomata  constitute  the  most  bulky  of  the  mammary 
neoplasms,*  their  growth  is  so  capricious  that  an 
average  rate  of  increase  cannot  be  assigned  to  them. 

to  the  outside  of  the  right  nipple,  which  slowly  increased  until,  at  the  end  of 
six  years,  it  was  of  the  volume  of  the  fist.  It  then  began  to  grow  rapidly,  and 
measured,  at  the  time  of  operation,  twenty  inches  in  circumference,  or  twelve 
inches  and  a  half  transversely  and  vertically,  against  seven  and  five  inches  for 
the  opposite  breast.  The  subcutaneous  veins  were  only  slightly  enlarged  ;  the 
nipple  was  buried  in  a  crcscentic  fold ;  the  skin  was  everywhere  mobile  and  of 
normal  tint,  except  above  over  a  large  boss,  where,  for  two  square  inches,  it  was 
adherent,  attenuated,  of  a  bluish  tint,  and  pervaded  by  minute  vessels ;  the  out- 
line of  the  breast  was  smooth  and  regular,  except  above,  where  it  was  bossed ;  the 
gland  was  freely  mobile  on  the  chest ;  the  temperature  was  five  degrees  higher 
than  that  of  the  opposite  breast ;  and  the  axillary  glands  were  not  involved. 
Throughout  its  entire  course,  the  tumor  was  absolutely  painless.  The  patient's 
menses  were  regular ;  there  was  no  history  of  trauma  or  heredity ;  but  both 
nipples  had  been  the  seat  of  psoriasis  ever  since  she  could  remember,  and  she 
frequently  picked  off  the  crusts. 

After  removal  by  Professor  Gross,  in  May,  1879,  the  breast  weighed  nearly 
three  pounds.  On  section,  there  was  an  escape  of  a  bloody  fluid,  and  the  cut 
surfaces  were  of  a  dark-red  color,  and  interspersed,  here  and  there,  with  dilated 
ducts,  a  few  of  which  contained  delicate  vegetations.  Above,  and  correspond- 
ing with  the  altered  integument,  there  was  a  large  softening  cyst,  occupied  by 
fluid  blood.  Below  the  remains  of  the  gland  were  seen  to  be  flattened  and 
spread  out.  The  neoplasm  itself  was  surrounded  by  a  capsule.  The  patient 
was  free  from  a  return  ten  months  after  the  operation. 

'  Cases  of  Hubert  and  Kirmisson,  Bull,  de  la  Soc.  Anat.,  t.  xlviii,  p.  389, 
and  t.  xlix,  p.  457. 

^  Pltres,  Jbid.,  t.  xlviii,  p.  706. 

^  Cases  of  Monod  and  Bordier,  Ibid.,  t.  li,  p.  531,  and  t.  xxxix,  p.  96. 

*  In  his  inaugural  dissertation,  Ueber  Fibro-Adenom  der  Mamma,  Gottingen, 
1878,  p.  13,  Dr.  Watson  narrates  a  case  from  the  practice  of  Dr.  Kremer,  in 
which  the  tumor  weighed  twenty-two  pounds. 


COMPLICATIONS.  85 

On  tlie  whole,  however,  one  is  justified  in  concluding 
that  the  small-celled,  the  cystic,  the  myxomatous,  and 
the  telangiectatic  increase  more  rapidly  than  the  large- 
celled,  the  solid,  and  the  pure  tumors. 

The  active  growth  of  sarcomata  is  liable  to  be  at- 
tended with  marked  elevation  of  the  temperature,  as 
was  noted  in  the  case  detailed  in  the  fores-oins:  foot- 
note,  and  in  one  of  my  own  cases,  in  which  Seguin's 
surface  thermometer  indicated  100°  as-ainst  95°  for  the 
opposite  breast.  In  two  other  examples  of  cystic  sar- 
coma there  was  an  increase  in  the  heat,  as  roughly  esti- 
mated by  the  hand.  All  of  these  tumors  were  highly 
vascular  and  composed  of  small  cells,  so  that  eleva- 
tion of  the  temperature  may  be  said  to  be  charac- 
teristic of  telangiectatic  and  rapidly  proliferating 
growths.  Further  investigations  in  this  direction 
may  prove  useful  in  determining  the  differential  diag- 
nosis of  the  connective  tissue  neoplasms,  and  should 
not  be  neglected. 

During  their  further  progress  sarcomata  continue, 
as  a  rule,  mobile  and  free  from  superficial  or  deep  at- 
tachments ;  the  skin  remains  natural  in  color  and  tex- 
ture ;  the  subcutaneous  veins  are  not  enlarged ;  the 
nipple  is  normal ;  and  the  associated  lymphatic  glands 
are  not  contaminated.  To  these  general  statements 
some  exceptions  must  be  noted. 

a.  While  it  is  not  imcommon  for  recurrent  tumors 
to  be  more  or  less  closely  attached  to  the  pectoral 
muscle,  and  through  it  to  the  walls  of  the  chest,  it 
is  a  singular  fact  that  the  primary  gro^vth  is,  almost 
without  exception,  freely  movable,  and  unattached 
even  to  the  common  integument.  In  a  case  recorded 
by  Zambianchi,  and  it  was  an  example  of  two  growths 


86  SARCOMA. 

in  the  same  breast,  tlie  outlying  tumor  developed 
over  the  upper  costal  cartilages  to  wliicb.  it  adhered, 
and  sent  a  prolongation  into  the  thorax/  In  six  in- 
stances the  neoplasms  were  slightly  adherent  to  the 
skin,  and  in  two  of  these  the  attachment  was  in  the 
immediate  vicinity  of  ulcers. 

/3.  Although  the  skin  may  be  stretched  and  at- 
tenuated, and  ulcerated,  as  I  showed  in  one-fourth  of 
all  examples,  it  was  discolored  in  only  sixteen,  or  in 
26*6  per  cent.,  and  it  is  interesting  to  know  that  the 
changes  in  tint  occurred  twelve  times  in  the  cystic 
and  four  times  in  solid  gro^\i;hs  which  were  the  seat 
of  degeneration-cysts.  In  eight  it  was  slightly  red, 
in  four  bluish,  in  two  intensely  red,  in  one  violace- 
ous, and  in  one  livid. 

7«  The  superficial  veins  were  enlarged  in  eleven 
instances,  or  in  18'3  per  cent.,  but  only  to  a  slight 
extent  in  two.  In  nine  the  tumor  was  cystic,  and  in 
two  it  was  solid,  but  in  the  latter  it  was  the  seat  of 
extravasation  of  blood  in  one,  and  of  mucoid  cysts  in 
the  second. 

S-  The  nipple  was  retracted  in  only  two,  and  these 
were  examples  of  cystic  growths. 

e.  In  one  case  of  ulcerated,  spindle-celled,  cystic 
sarcoma,"  the  glands  of  the  axilla  were  slightly  ten- 
der and  enlarged,  as  the  result  of  irritation ;  and,  in 
another  instance,  an  enlarged  gland,  which  was  also 

'  Ante.  Lagrange  and  Buret  {Bull,  de  la  Soc.  Anat,  t.  xlviii,  p.  516)  refer 
to  a  ease  in  which,  on  post-mortem  examination  of  a  female  who  had  for  many 
years  an  enormous  sarcoma  of  the  breast,  the  tumor  separated  the  fibres  of  the 
pectoral  muscles,  passed  between  two  ribs  into  the  cavity  of  the  mediastinum, 
and  penetrated  between  and  compressed  the  lobes  of  the  lung  without  infecting 
any  of  these  structures. 

'  Birkett,  Trans.  Path.  Soc.  London,  vol.  xx,  p.  357. 


DISCHARGE  FROM  NIPPLE.  87 

devoid  of  tumor  elements,  was  removed  along  witli  a 
recurrent,  fungating,  spindle-celled  tumor.'  This  im- 
munity of  the  glands  from  contamination  is  remark- 
able, and  is  a  valuable  sign  in  the  differential  diag- 
nosis of  malignant  mammary  growths. 

A  discharge  from  the  nipple  occurs  in  one  case 
out  of  every  seven  of  cystic  sarcomata,  the  proportion 
being  almost  precisely  the  same  as  is  met  with  in 
cj^'stic  fibromata,  and  is  of  great  value  as  a  symptom 
of  enlargement  of  the  ducts,  although  it  is  of  itself 
unimportant  in  the  differential  diagnosis.  In  an 
instance  from  the  practice  of  Bryant,*  a  viscid  dis- 
charge was  the  first  symptom,  and  preceded  the  de- 
tection of  the  tumor  by  two  years.  When  it  recurred 
the  suffering  diminished,  and  it  was  sanguinolent  just 
before  the  removal  of  the  breast,  or  eight  years  from 
the  first  appearance  of  the  growth.  In  a  second  case, 
recorded  by  that  surgeon,'  the  flow  was  bloody,  and 
derived  from  highly  vascular  vegetations.  In  the  case 
of  Hubert,*  the  tumor  augmented  in  size  at  each 
menstrual  period,  when  there  was  an  occasional  dis- 
charge of  a  citron-colored  liquid.  In  that  of  Bill- 
roth,* in  which  the  neoplasm  developed  during  preg- 
nancy, there  was  an  occasional  escape  of  a  serous 
fluid;  while  in  the  case  of  Lebert,'  in  which  the 
growth  appeared  three  months  after  parturition,  a 
viscid,  transparent  liquid  was  expelled  by  pressure. 

Contrary  to  the  usual  statements,  the  growth  of 

'  Anderson,  Trans.  Path.  Soe.  London,  vol.  xxiii,  p.  254. 

*  Guy's  Hospital  Reports,  ser.  3,  vol.  x,  p.  115. 
'  Ibid.,  p.  120. 

*  Bull,  de  la  Sac.  Anat.,  t.  xlviii,  p.  389. 
»  Chir.  Klinik,  Wien,  1869-'YO,  p.  142, 

*  Physioloffie  Pathologique,  t.  ii,  p.  128. 


88  SARCOMA. 

sarcomata  is  attended  witli  pain,  since,  of  forty-one 
cases  in  whicli  tliat  symptom  is  noted,  it  was  pres- 
ent in  twenty-six,  or  63-4  per  cent.,  while  it  was  en- 
tirely absent  in  fifteen,  or  36'6  per  cent.  In  only 
two  examples,  however,  was  attention  first  called  to 
the  tumor  by  suffering,  and,  in  the  remainder,  it  de- 
clared itself  later,  and  varied  in  character  and  fre- 
quency in  accordance  with  the  variety  of  the  sarcoma. 
Thus,  in  the  solid  form  it  was  experienced  in  only 
30  per  cent,  of  the  cases,  and  was  merely  of  an  occa- 
sional pricking  nature.  In  the  cystic  variety,  on  the 
other  hand,  it  was  felt  in  78  per  cent,  of  the  cases, 
and  in  three-fourths  of  these  it  came  on  late  in  the 
disease,  especially  during  rapid  growth,  when  the 
tumor  became  tense  through  the  increase  of  the  con- 
tents of  the  cysts,  and  it  was  of  a  severe  and  lanci- 
nating character.  In  20  per  cent,  of  these  cases  it 
was  only  experienced  when  ulceration  had  set  in, 
although  ulceration  and  fungous  protrusion  did  not 
sensibly  affect  the  suffering,  since  it  was  not  aug- 
mented by  these  conditions  in  60  per  cent.,  while  it 
was  entirely  absent  in  20  per  cent,  of  all  examples. 
In  one  instance  it  was  felt  only  at  the  menstrual 
periods ;  while  in  two  it  was  aggravated,  and  in  one 
diminished,  at  that  period.  In  only  one  case  was  the 
growth  absolutely  tender,  although  in  many  examples 
it  was  annoying  from  its  weight  and  bulk. 

During  their  further  progress,  as  we  have  already 
seen,  sarcomata  may  invade  their  limiting  capsules  and 
the  neighboring  tissues,  and  finally  ulcerate.  With- 
out, however,  of  necessity  pursuing  this  course,  their 
capsules  may  remain  intact,  but  none  the  less  may 
they  extend   to  the   adjacent   structures   along  the 


PROGNOSIS.  89 

course  of  tlie  bloodvessels,  the  adventitia  of  whicli 
is  frequently  the  seat  of  small-celled  proliferation, 
throuo-li  which,  the  tissues  are  converted  into  "latent 
zones  of  infection " ;  these  zones  are  not  appreciable 
by  the  naked  eye,  but  serve  not  only  as  the  points  of 
departure  of  the  recurrences  that  are  so  often  wit- 
nessed after  their  removal,  but  also  as  foci  of  general 
infection  with  the  production  of  deposits  in  the  in- 
ternal organs.  Hence  it  is  that  the  prognosis  of  sar- 
comata is  eminently  unfavorable,  although  there  is  still 
no  little  diversity  of  opinion  among  practical  sur- 
geons and  pathologists  on  this  point.  Thus,  Wilks 
and  Moxon,'  Cornil  and  Ranvier,''  Labbe  and  Coyne,' 
and  Erichsen*  regard  them,  and  particularly  the 
cystic  form,  as  being  comparatively  innocent,  and 
only  marked  by  a  tendency  to  local  reproduction. 
Labbe  and  Coyne  and  Erichsen  deny  the  possibility 
of  the  general  dissemination  of  spindle-celled  tumors ; 
and  Erichsen,  indeed,  advances  the  singular  doctrine 
that  "  the  tendency  to  recurrence  will  in  most  cases 
gradually  wear  itself  out,  and  after  several  operations 
have  been  required  at  intervals  of  months,  or  a  year 
or  two,  the  disease  will  cease  to  be  reproduced,  and 
a  cure  will  be  thus  established  "  ;  although,  he  adds, 
that  "  instances  are  not  wanting  in  which  the  ten- 
dency to  the  local  reproduction  of  the  sarcoma  has 
been  so  active  that  it  outran  all  possibility  of  com- 
plete extirpation,  and  eventually  destroyed  the  pa- 
tient." Virchow^  states  that,  while  sarcoma  may 
recur  in  loco,  "  it  is  a  tumor  of  limited  malignity,  but 

*  Lectures  on  Path.  Anatomy,  p.  584,  1875.  *  Op.  cit.,  p.  1162. 
^  Op.  cit.,  p.  431. 

*  77ie  Science  and  Art  of  Surgery,  p.  565.     Phil.,  IS'TS. 
'  Op.  cit.,  p.  362. 


90  SARCOMA. 

fully  capable  of  producing  metastases  " ;  and  Liicke ' 
indorses  this  view.  Bii'kett/  Gross,'  Ashliui'st/ 
Klebs/  and  Billrotli/  on  tlie  other  hand,  fully  recog- 
nize the  malimant  attributes  of  sarcomata  as  denoted 
by  their  capability  of  reproducing  themselves,  not 
only  in  the  neighboring  tissues,  but  also  in  remote 
parts ;  and  other  writers  regard  their  progress  as  be- 
ing "  much  more  favorable  "  than  that  of  mammary 
carcinoma. 

With  the  view  of  clearing  up  the  obscurity  which 
exists  in  regard  to  the  prognosis  of  sarcoma  of  the 
mammary  gland,  I  have  carefully  studied  the  cases 
in  which  the  histories  are  complete,  relying  entirely 
upon  the  sLxty  examples  which  afford  the  basis  of 
this  chapter,  and  which  have  been  collated  without 
selection.  Dividing  them,  in  accordance  with  their 
stiTicture,  I  find 

First.  Round-celled  tumors,  whether  solid  or  cys- 
tic, or  whether  they  pursue  a  natural  course,  or  be 
subjected  to  operation,  are  excessively  malignant. 
Thus,  in  a  case  recorded  by  Bilh'oth,'  a  sarcoma  of 
the  left  breast  of  a  pregnant  woman,  aged  thirty-one 
years,  was  succeeded,  in  four  months,  by  a  similar 
growth  in  the  opposite  mamma.  She  was  not  inter- 
fered with,  and  during  the  last  few  weeks  suffered 
from  continued  fever,  cough,  and  expectoration,  and 

*  Pitha  and  Billroth's  Hdbch.  der  AUg.  und  Spec.  CJiir.,  Bd.  ii,  Abth.  i,  p. 
194. 

2  Holmes's  System  of  Surgery,  2d  ed.,  vol.  v,  p.  269. 

*  System  of  Surgery,  5th  ed.,  vol.  ii,  p.  984. 

*  Fhila.  Med.  Times,  vol.  ix,  p.  384,  1879. 
5  Op.  cit.,  p.  Ills. 

*  Surgical  Pathology,  by  Hackley,  p.  606  ;  and  Pitha  and  BiUrotK's  Edbch., 
Bd.  iii,  Abth.  ii.  Lief,  i,  p.  97. 

'  Chir.  Klinik,  Wicn,  1869-1870,  p.  142. 


1 


PEOGN-QSIS.  91 

died  in  seven  montlis  from  the  first  observation  of 
the  disease.  An  inspection  of  the  body  could  not  be 
obtained ;  but  the  chest  symptoms  pointed  to  second- 
ary tumors  in  the  lungs. 

If  the  patient  survives  an  operation,  recurrence 
may  be  looked  for.  Thus,  of  ten  instances,  local  or 
general  reproduction  was  witnessed  in  eight,  five  of 
which  occurred  within  half  a  year,  one  in  fifteen 
months,  one  in  three  years,  and  one  in  five  years,  the 
average  date  having  been  not  quite  eighteen  months. 
A  patient  of  my  own  died  with  a  recurrent  gi^owth 
in  nine  months  after  the  removal  of  the  primaiy 
tumor,  but  without  metastatic  deposits,  the  total 
duration  of  life  having  been  thirty-three  months ;  * 
one  died  after  two  recurrences  and  a  supposed  sec- 
ondary growth  pressing  upon  the  sciatic  nerve,  in  the 
short  period  of  nine  months  from  the  commencement 
of  the  disease ; "  one  died  of  a  round-celled  sarcoma 
of  the  cerebellum  three  years  after  the  extirpation  of 
the  breast ; '  one  died,  in  twenty-seven  months,  of 
secondary  tumors  in  the  left  lung,  having  in  the 
meanwhile  been  subjected  to  five  operations ;  *  while 
one  succumbed  from  scirrhus  of  the  opposite  breast, 
in  two  years  and  a  half,  without  recurrence.^  One 
patient  was  living  at  the  end  of  thirty-one  months, 
having  undergone  two  operations  for  recurrence ;  * 
one  was  alive  eleven  months  subsequently,  but  had 
submitted  to  three  additional  operations,  and  declined 

*  Phila.  Med.  Times,  vol.  ix,  p.  383. 

*  Hewson,  Gi-oss's  Surgery,  5th  ed.,  vol.  ii,  p.  985. 
*Edes,  Amer.  Joiir.  Med.  Sciences,  vol.  Ixi,  p.  90. 

*  Kramer,  Watson^s  Inaug.  Diss.,  ante,  p.  1 3. 

*De  Morgan,  Trans.  Path.  Soc.  Lond.,  vol.  xix,  p.  394. 

*  Gerin-Rose,  Bull,  de  la  Soc.  Anat.,  vol.  xxxiii,  p.  211. 


92  SARCOMA. 

further  interference  for  a  foui-tli  recurrence;*  one 
was  living,  with  a  large  recurrent  growth,  four  months 
after  the  removal  of  the  breast;"  one  underwent 
another  operation  at  the  expiration  of  five  years;' 
while  one  was  living  ten  months  subsequently  with- 
out recurrence/  It  will  thus  be  seen  that,  of  ten 
patients  who  submitted  to  operation,  in  only  two  was 
there  no  evidence  of  local  reproduction  or  general 
dissemination ;  but,  as  recurrence  may  be  delayed  for 
five  years,  these  cases  prove  nothing,  since  one  died 
of  another  affection  in  two  years  and  a  half,  and 
one  was  alive,  free  from  disease,  at  the  end  of  ten 
months. 

Secondly.  The  prognosis  of  spindle-celled  sarco- 
mata is  scarcely  more  favorable.  Thus,  of  sixteen 
examples,  one  was  living,  free  from  disease,  several 
months,"  one  six  months,"  one  fifteen  months,'  one 
twenty-six  months,"  and  one  five  years  after  opera- 
tion, the  subject  of  the  last  case  suffering  from  en- 
largement of  the  axillary  glands,  "  which  soon  proved 
to  be  due  to  cancerous  deposit." '  In  the  remaining 
eleven  there  was  local  or  general  recurrence,  which 
appeared,  on  an  average,  in  thirteen  months.  One 
was  alive  at  the  end  of  nine  years,  five  recurrent 
growths  having  been  removed  in  that  period ;  but  the 
case  was  recorded  immediately  after  the  last  opera- 

'  Gerin-Rose,  Bull,  de  la  Soc.  Anat.,  vol.  xxxiii,  p.  281. 
'  Billroth,  Virchoio^s  Archiv,  Bd.  xviii,  p,  69. 

*  Kuester,  Langenhcck's  Archiv,  Bd.  xii,  p.  619. 
4  Ibid. 

*  Eeverdin,  Bull  de  la  Soc.  Anat.,  t.  xViv,  p.  2S1. 
*Lefort,  Oaz.  des  Hopitaux,  No.  51,  1869,  p.  196. 

'  Gross,  System  of  Surrjery,  5th  cd.,  vol.  ii,  p.  986. 
8  Billroth,  Chir.  Klinik,  Wien,  1869-'70,  p.  142. 
'Pick,  Trails.  Path.  Soc.  London,  vol.  xx,  p.  347. 


PROGNOSIS.  93 

tion ; '  one  was  alive  at  the  end  of  fourteen  months 
after  the  removal  of  a  recurrent  growth  of  six 
months'  standing,  but  this  case  also  was  reported 
soon  after  the  operation ; '  one  had  just  submitted  to 
the  removal  of  a  recurrent  growth  at  the  expiration 
of  thirty-two  months ; '  one  was  living  with  a  seventh 
recurrence  at  the  end  of  ten  years,  six  tumors  having 
been  removed  in  the  meantime ;  *  and  one  under- 
went twenty-two  operations  for  fifty-one  recurrent 
growths  in  four  years,  and  was  perfectly  well  for 
upward  of  ten  years  subsequently,  so  that  the  patient 
may  be  regarded  as  having  been  cured/  Of  the  six 
that  died,  in  one  the  disease  returned  in  three  weeks, 
and  again  recurred  one  week  after  its  removal ;  but 
the  patient  succumbed  at  her  home,  so  that  there  was 
no  post-mortem  inspection ;  *  in  one  there  was  recur- 
rence in  less  than  six  weeks,  and  a  second  tumor 
appeared  after  its  extu^pation  ;  but  the  woman  died  of 
exhaustion,  and  there  were  no  metastatic  deposits, 
although  the  tumor  extended  into  the  chest  ;^  in 
one  there  were  three  recurrences  in  thirteen  years, 
and,  on  death  from  the  effects  of  the  last  operation, 
the  tumor  was  found  to  have  projected  slightly  into 
the  pleural  cavity,  but  the  viscera  were  healthy ;  *  in 
one  there  was  recurrence  in  fourteen  weeks,  and,  on 
death  without  operation  in  two  months,  the  tumor 

'  Gay,  Trans.  Path.  Soc.  London,  vol.  xvi,  p.  240 ;  vol.  xx,  p.  359 ;  and  vol. 
XXV,  p.  233. 

*  Herpin,  B^dl.  de  la  Soc.  Anat.,  t.  xlix,  p.  633. 

^Neftel  and  Howard,  The  Medical  Record,  vol.  iv,  p.  356,  and  vol.  viii,  p.  15. 

*  Heath,  British  Med.  Journal,  vol.  i,  1S7S,  p.  194. 

*  Gross,  Op.  cit.,  vol.  ii,  p.  985. 

*  Anderson,  Trans.  Path.  Soc.  London,  vol.  xxiii,  p.  254. 
'  Nunn,  Ibid.,  vol.  xviii,  p.  255,  and  vol.  xix,  p.  380. 
^Haward,  Trans.  Clin.  Soc.  London,  vol.  viii,  p.  107. 


94  SARCOMA. 

was  found  to  have  perforated  tlie  cliest,  and  tliere 
were  metastatic  deposits  in  tlie  lungs,  mediastinum, 
liver,  ribs,  vertebrae,  pelvic  bones,  dura  mater,  and 
sphenoid  bone ; '  in  one  a  secondary  growth  devel- 
oped in  the  right  thigh  at  the  end  of  two  months, 
and  on  death,  eleven  months  subsequently,  another 
voluminous  tumor  was  found  in  the  left  thigh,  but  a 
post-mortem  examination  could  not  be  obtained ; " 
and,  finally,  one  died  of  metastatic  tumor  of  the  brain 
and  parietal  bone,  of  twenty-three  months'  duration, 
two  years  and  a  half  after  the  removal  of  the  breast/ 
From  the  preceding  facts  it  appears  that  the  case 
which  ran  a  natural  course,  and  which  was  an  illus- 
tration of  symmetrical  disease,  proved  fatal,  with  pre- 
sumed secondary  deposits,  in  seven  months  from  the 
time  the  growth  was  first  obsei'ved ;  while,  of  the 
twenty-six  that  were  subjected  to  operation,  six  were 
living  free  from  disease  for  an  average  period  of  two 
years ;  one  died  ^\dthout  evidences  of  local  or  general 
infection ;  and  nineteen  were  examples  of  local  return 
or  dissemination.  Of  these  nineteen,  nine  had  had 
one  or  more  recurrences,  and  were  still  alive  at  the 
date  of  the  reports ;  four  died  with  recurrence,  but 
without  metastases ;  one  died  mth  recurrence  and 
supposed  visceral  implication ;  two  died  A^dth  both 
local  and  general  tumors ;  and  three  died  of  metas- 
tases, but  ^^dthout  local  reproduction.  It  is,  more- 
over, interesting  to  note  that  recurrence  was  met  with 
just  as  frequently  after  the  entire  removal  of  the 
breast  as  after   partial  operations,  and  that  it  was 

•  Virchow,  Virchow's  Ardiiv,  Bd.  ix,  p.  618. 
2  Bennett,  Cancerous  and  Cancroid  Groivlhs,  pp.  12  and  256. 
^  Volkmann,  Bemerkungen  iiber  einige  von  Krehs  zu  trennende  Geschimlste, 
p.  32. 


PROGNOSIS.  95 

certainly  due  to  local  infection  in  all  except  possibly 
one,  in  wMcli  multiplicity  of  the  original  growth  may 
have  denoted  the  further  development  of  nodules 
which  escaped  observation  at  the  first  enucleation. 

While  it  is  naturally  impossible  to  say  what  course 
the  disease  subsequently  pursued  in  the  patients  in 
whom  there  were  no  signs  of  recurrence  for  two  years 
after  operation,  it  is  not  unreasonable  to  suppose  that 
it  proved  infectious,  either  locally  or  generally,  in 
some  of  the  cases,  and  the  termination  cannot  be 
doubted  in  those  who  were  li\dnoj  with  recurrent  tu- 
mors.  Be  this  as  it  may,  the  fact  remains  that  mam- 
mary sarcoma  recurs  locally  in  61*53  per  cent,  of  all 
instances,  and  that  it  gives  rise  to  secondary  deposits 
in  distant  organs  in  57*14  per  cent.,  since  local  repro- 
duction was  met  with  in  sixteen  out  of  twenty-six 
cases,  and  metastatic  tumors  were  discovered  in  four 
out  of  seven  post-mortem  examinations. 

While  sarcoma  recurs  less  frequently  and  not  so 
rapidly  as  carcinoma,  it  is  more  liable  to  \4sceral  com- 
plications than  is  the  latter.  As  we  have  just  seen, 
61*53  j)er  cent,  of  the  sarcomata  are  locally  infectious ; 
while,  as  will  be  pointed  out  in  the  chapter  on  that 
affection,  carcinoma  reproduces  itseK  in  80*97  per  cent, 
of  all  instances.  Of  twelve  cases  of  sarcoma  in  which 
the  date  is  noted,  eight,  or  66  per  cent.,  developed 
again  in  less  than  one  year,  or  in  a  period  which  va- 
ried from  three  weeks  to  eight  months;  while  the 
others  appeared,  respectively,  in  fifteen,  eighteen, 
thirty-two,  and  sixty  months.  In  carcinoma,  on  the 
other  hand,  88*35  per  cent,  of  the  local  recuiTences 
are  met  with  in  the  first  year.  Inspection  after  death 
discloses  metastatic  tumors  in  57*14  per  cent,  of  the 


96  SARCOMA. 

sarcomata,  against  50  per  cent,  of  the  carcinomata ; 
and  presumed  metastases  are  more  frequent  by  3  per 
cent,  in  tlie  former  than  in  the  latter.  Hence,  sarco- 
ma is  less  infectious  locally,  but  more  infectious  as  re- 
gards the  general  system,  than  carcinoma.  Its  more 
relatively  benign  character  is,  moreover,  shown  by  the 
fact  that  the  average  duration  of  life,  from  the  first 
observation  of  the  disease  to  the  date  of  the  last  re- 
port after  removal,  is  seven  years,  against  thirty-seven 
months  for  carcinoma ;  and  this  contrast  becomes  the 
more  striking  when  it  is  stated  that  the  majority  of 
the  sarcomatous  patients  were  still  living,  while  the 
majority  of  the  carcinomatous  subjects  were  dead. 
Not  only  is  this  statement  true  for  all  sarcomata,  but 
it  holds  good  for  the  two  principal  varieties,  since  the 
average  life  for  round -celled  sarcoma  is  four  years, 
and  seven  years  and  a  half  for  the  spindle-celled. 

Although  the  recurrent  regional  disease  is  more 
intense  than  the  primary,  and  other  reproductions 
generally  follow  in  quick  succession,  there  can  be  no 
doubt  that  the  removal  of  the  tumors,  as  fast  as  they 
appear,  alleviates  suffering,  prolongs  life,  and  averts 
visceral  contamination.  Thus  Gay  enucleated  from 
the  same  breast  two  cystic  growths,  both  of  which 
recurred  and  were  removed  with  the  entire  gland  in 
eighteen  months.  They  appeared  again  and  were 
extirpated  in  thirty  months ;  and  a  third  and  single 
recurrent  tumor  was  excised  in  five  years,  so  that  life 
was  prolonged  for  nine  years,  or  for  fifteen  years  from 
the  first  appearance  of  the  disease  up  to  the  date  of 
the  last  report.  In  Heath's  case  there  were  seven 
recurrences  in  thirteen  years,  but  the  last  was  not 
subjected   to   operation.      In  that   of   Haward,   the 


PROGNOSIS.  97 

primary  growtli  was  excised  in  1860,  and  recurrent 
growths  were  removed  in  1863, 1869,  and  1873.  The 
patient  died  from  the  effects  of  the  last  operation,  but 
life  was  prolonged,  as  in  the  preceding  instance,  for 
thirteen  years.  The  case  of  Gross,  however,  is,  as  far 
as  I  know,  the  most  remarkable  on  record.  In  March, 
1857,  a  single  woman,  aged  forty-four,  discovered  a 
small  tumor  in  the  left  breast,  which  was  enucleated 
the  following  October.  During  the  next  sixteen 
months  two  more  partial  operations  were  performed ; 
and  a  foui'th  tumor,  along  with  the  entire  breast,  was 
extii-pated  in  May,  1859.  In  three  months  and  a  half 
the  knife  was  again  required,  and  soon  afterward 
other  tumors  were  removed.  In  1860  she  underwent 
eleven  operations,  and  six  in  1861,  the  last  of  which 
was  performed  in  September  of  that  year,  so  that  she 
was  subjected  to  twenty -two  operations  in  four  years. 
The  number  of  recurrent  tumors  was  fifty-one,  and 
they  varied  in  size  from  an  almond  to  a  hen's  e^g. 
They  appeared  at  or  near  the  cicatrices  within  a  few 
weeks,  and  rapidly  assumed  a  fungating  aspect.  Large 
portions  of  the  j^ectoral,  and  also  of  the  external  and 
internal  intercostal  muscles,  were  cut  away,  so  that 
during  a  deep  inspiration  there  was  a  slight  protru- 
sion of  the  pleura.  Ten  years  and  nine  months  after 
the  last  operation  she  was  in  perfect  health.  In  these 
four  cases  the  tumors  were  composed  of  spindle  cells ; 
there  was  no  lymphatic  involvement,  and  the  general 
health  was  unimpaired. 

The  prognosis  is  materially  influenced  by  the  age 

of  the  patient  and  by  the  size  and  rate  of  increase  of 

the  tumor.     Thus  in  young  persons,  or  before  the 

age  of  thirty -five,  when  the  gland  is  functionally  most 

7 


98  SARCOMA. 

active,  a  small,  slowly  growing  sarcoma  does  not  re- 
turn, wliile  a  rapidly  increasing  cystic  tumor  is  very 
liable  to  recur.  Among  the  latter  class  of  cases,  66 
per  cent,  of  the  tumors  recurred,  and  33  per  cent, 
remained  well.  After  the  thirty-fifth  year,  on  the 
other  hand,  and  the  danger  increases  mth  advancing 
age,  the  greater  is  the  liability  to  metastases,  as  in 
this  class  of  cases  33  per  cent,  were  generalized,  40 
per  cent,  recurred,  and  27  per  cent,  remained  free 
from  disease. 

The  prognosis  is  also  influenced  by  the  histological 
constitution  of  the  tumor  and  the  stas-e  of  its  evolu- 
tion.  Of  the  spindle-celled  56*25  per  cent,  recurred, 
and  18*75  per  cent,  gave  rise  to  metastatic  growths  ; 
of  the  round-celled  70  per  cent,  recurred,  and  30  per 
cent,  were  generalized ;  of  the  cystic  53*3  recurred, 
and  13*3  per  cent,  were  disseminated;  while,  of  the 
solid,  55*5  per  cent,  recurred,  and  22*2  were  gener- 
alized. Hence,  while  the  round-celled  are  to  be  re- 
garded as  the  most  pernicious,  the  metastasis  of  the 
spindle-celled  is  by  no  means  to  be  denied ;  nor  can 
one  say,  with  Erichsen,  that  the  cystic  variety  tends 
to  wear  itseK  out  by  repeated  operations,  since  it 
recurs  almost  as  frequently  as  the  solid  variety, 
although  the  latter  reproduces  itseK  in  distant  parts 
in  9  per  cent,  more  of  the  cases.  These  investigations 
demonstrate  that  the  usual  statements,  which  are  so 
opposed  to  the  actual  facts,  as  to  the  malignity  of 
sarcomata,  are  due  either  to  their  not  having  been 
based  upon  a  careful  analysis  of  recorded  cases,  con- 
firmed by  minute  examination,  or  to  the  confound- 
ing of  cystic  sarcomata  with  cystic  fibromata,  which 
never  infect  the  economy. 


DIAGNOSIS.  99 

The  diagnosis  of  small,  slowly  increasing  fibrous 
sarcomata  is  by  no  means  always  easy,  as  tliey  are 
very  liable  to  be  confounded  with,  fibromata,  particu- 
larly when  they  arise  at  the  circumference  of  the 
mamma.  A  tumor,  however,  of  soft,  elastic,  appar- 
ently fluctuating  consistence,  which  attains  the  vol- 
ume of  an  adult  head  in  a  few  months,  can  scarcely 
be  anything  else  than  a  small-celled  sarcoma.  On  the 
whole,  the  diagnosis  is  based  upon  their  indolent  ori- 
gin, mobility,  central  situation,  elastic,  o;'  unequal 
consistence,  lobulated  outline,  rapid  increase,  large 
dimensions  for  the  period  of  their  existence,  fi^eedom 
fi'om  lymphatic  involvement,  their  marked  tendency 
to  ulcerate,  the  not  infrequent  discoloration  of  the 
skin  and  enlargement  of  the  subcutaneous  veins,  and 
possibly  elevation  of  temperature ;  upon  the  suffering 
which  they  awaken  late  in  the  disease ;  and  upon  their 
greatest  frequency  after  the  thirty -fiftk  year. 

Between  the  solid  and  cystic  varieties  there  are 
certain  distinctions,  whicli  are  useful  in  establishing  a 
differential  diagnosis.  The  former  develop  at  about 
the  thirty-seventh  year;  the  skin  is  discolored  in  16 
per  cent.,  and  adherent  in  12  per  cent. ;  the  veins 
are  dilated  in  8  per  cent. ;  there  is  no  discharge  from 
the  nipple,  nor  is  it  retracted ;  pain  is  met  mth  in  30 
per  cent.,  but  it  is  sligkt ;  the  tumor  ulcerates  in  12 
per  cent.,  and  it  is  characterized  by  malignant  features 
in  77  per  cent,  of  all  instances.  Cystic  sarcoma  starts 
at  the  thirty -tkird  year ;  it  grows  more  rapidly  than 
the  solid  variety,  and  its  increase  is  often  sudden 
after  having  remained  stationary  or  advanced  slowly 
for  some  time.  Now  and  then,  after  evacuation  of 
the  fluid  of  the  superficial  cysts,  their  solid  contents 


100  SARCOMA. 

can  be  detected  by  manipulation ;  tlieir  consistence 
is,  as  a  rule,  unequal,  and  they  are  more  largely  lobu- 
lated  tlian  tlie  former  variety.  The  skin  is  discolored 
in  34  per  cent.,  being  of  a  bluish  tint  in  one-third  of 
all  cases  over  the  most  prominent  cysts,  and  it  is  ad- 
herent in  11  per  cent. ;  the  veins  are  enlarged  in  25 
per  cent. ;  the  nipple  is  retracted  in  5-71  per  cent., 
and  discharges  fluid  in  14*28  per  cent. ;  ulceration 
occurs  in  34'28  per  cent. ;  pain  is  experienced  in  78 
per  cent.,  and  it  is  usually  harassing ;  while  the  dis- 
ease is  malignant  in  64  per  cent,  of  all  cases. 


CHAPTEE   YII. 


MTXOJUA. 


Of  tlie  connective  tissue  neoplasms  of  tlie  mam- 
mary gland  by  far  tlie  most  rare  is  that  denominated 
myxoma  by  Virchow,  wliich  is  synonymous  with  tlie 
collonema  of  Miiller,  tlie  gelatinous  sarcoma  of  Roki- 
tansky,  the  net-celled  sarcoma  of  Billroth,  the  soft 
and  succulent  form  of  fibrocellular  tumor  of  Pag-et, 
and  the  colloid,  mucous,  or  gelatinous  tumor  of  other 
pathologists.  Rindfleisch  briefly  describes  it  as  cysto- 
sarcoma  mucosum ;  and  Birkett  refers  to  it  as  colloid 
growth ;  but  the  history  of  its  life  is  lost  in  that  of 
colloid  carcinoma.  I  have  myself  never  met  with  it, 
although  I  recently  examined  a  specimen  removed  by 
my  friend.  Dr.  J.  M.  Barton;  and,  after  careful  re- 
search, I  have  been  able  to  collect  only  ten  examples, 
confirmed  by  minute  inspection. 

In  structure,  pure  or  hyaline  myxoma  has  its  phys- 
iological prototype  in  the  soft  rudimentary  connec- 
tive tissue  and  enamel  organ  of  the  foetus,  in  the 
AVhartonian  jelly  of  the  umbilical  cord,  and  in  the 
adult  vitreous  body.  It  consists,  as  is  represented  in 
fig.  13,'  of  a  meshwork  of  vessels,  the  spaces  between 

'  From  a  section  of  a  recurrent  tumor,  of  fifteen  months'  duration,  and  as  large 
as  an  egg,  removed,  with  the  breast,  by  Dr.  Barton,  from  a  single  woman,  in  whom 
the  primary  disease  developed  at  the  age  of  fifty -five,  or  seven  years  after  the 


102 


VARIETIES. 


whicli  are  filled  with  a  mucous  substance  beset  with 
round  and  oval,  but  more  especially  with  spindle  and 
stellate  cells,  from  which  numerous  filamentous  and 
anastomosing  processes  or  prolongations  are  given  off. 
Tumors  thus  constituted  have  a  translucent  greenish, 
yellowish,  or  yello^vish-gray  color,  are  of  soft,  jelly- 


Htaline  Myxoma. — Showing  the  characteristic  anastomosing  stellate  and  spin- 
dle cells,  as  well  as  round  cells,  which  are  contained  in  the  meshes  of  a  vas- 
cular network.     The  nuclei  in  the  walls  of  the  vessels  are  very  apparent. 


like  consistence,  and  yield,  on  pressui'e  or  scraping,  a 
clear,  sticky,  viscid,  or  filamentous  fluid,  similar  to  a 
solution  of  gum-arabic,  and  exhibiting  the  chemical 
characters  of  mucin. 

From  this  simple  type  of  structure  there  are  cer- 
tain deviations,  through  which  are  constituted  the 
followino;  varieties : 

a.  Medullary  Myxoma. — When  the  cells,  which, 
compared  with  the  intercellular  substance,  are  usu- 

menopause.  It  was  soft  and  pseudofluctuating ;  the  skin,  to  a  limited  extent,  was 
adherent,  and  had  a  bluish  tint ;  but  there  were  no  deep  attachments  or  other 
complications.  On  section,  the  cut  surfaces  were  of  a  dark-red  color,  and 
yielded,  on  pressure,  a  viscid  fluid.  The  entire  tumor  was  inclosed  in  a  delicate 
capsule,  which,  however,  was  broken  through  by  a  subcutaneous  fungus ;  this 
corresponded  to,  but  did  not  perforate,  the  thinned  and  discolored  skhu 


MYXOMA.  103 

ally  few  in  number,  proliferate  and  preponderate 
either  throusrliout  tlie  entire  mass  or  at  localized 
points,  and  tlie  tissue  lias  a  whitish,  opaque,  or  even 
an  encephaloid,  appearance,  the  term  medullary  is 
prefixed  to  the  growth. 

/3.  Lipomatous  Myxoma. — When,  on  the  other 
hand,  without  having  necessarily  multiplied,  the  cells 
are  converted  into  fat  cells,  and  the  gelatinous  mate- 
rial contains  firmer  areas  of  a  yellow,  yellowish- 
white,  or  brownish-white  tint,  the  tumor  is  known  as 
lipomatous  myxoma. 

7.  Fibrous  Myxoma. — If  the  mucoid  intercellular 
substance  is  pervaded  by  rather  abundant  ordinary 
connective  tissue  and  elastic  fibres  in  the  form  of  deli- 
cate bands  or  meshes,  the  neoplasm  is  converted  into 
a  fibrous  myxoma,  which  has  a  grayish  or  whitish 
tint,  is  tolerably  firm,  and  is  not  unlike  cedematous 
areolar  fibroma. 

S.  Cystoid  Myxoma. — If,  as  occasionally  happens, 
the  cells  themselves  undergo  mucoid  transformation 
and  disintegrate,  and  the  matrix  liquefies,  cystoid 
spaces  fiGded  with  less  consistent  mucoid  fluid  result, 
and  change  the  growth  into  a  cystoid  myxoma. 

e.  lelangiectatic  Myxoma. — Any  of  these  varieties 
may  become  so  vascular  through  the  new  formation 
of  vessels  as  to  constitute  telangiectatic  myxoma,  or, 
in  the  event  of  the  rupture  of  the  delicate  and  en- 
larged vessels  and  interstitial  bleeding,  hemorrhagic 
myxoma.  These  occurrences  are  denoted  by  the  ro- 
saceous, red,  dark-red,  or  bro^\Tiish-red  discoloration, 
and  even  by  vessels  which  are  visible  to  the  naked  eye. 

Hyaline  myxoma  is  not  common.  Of  seven  ex- 
amples in  which  the  minute  features  are  described, 


104  DEVELOPMENT. 

one  was  hyaline,  and  one  was  hyaline  and  liemor- 
rhagic ;  two  were  lipomatous,  and  two  telangiectatic 
and  lipomatous ;  while  one  was  fibrous  and  telangiec- 
tatic Hence  the  fatty  and  vascular  varieties  consti- 
tute the  majority. 

Like  the  other  histoid  neoplasms,  myxoma  ori- 
ginates in  the  interlobular  and  intei*tubular  connec- 
tive tissue,  which,  from  being  dense  and  resisting,  re- 
verts to  its  rudimentary  or  mucous  state.  Just  how 
often  the  adipose  tissue  of  the  gland  serves  as  its 
starting-point,  it  is,  of  course,  impossible  to  say ;  but 
a  case  recorded  by  Moore,  in  which  a  portion  of  the 
tumor  consisted  of  almost  pure  fat,  appears  to  favor 
the  idea  that  the  primaiy  growth  was  of  that  nature, 
and  that  the  fat  cells  had  returned  to  then*  embryonic 
condition. 

The  entire  mamma  may  be  converted  into  a  bulky 
mass,  or  one  or  more  lobules  may  alone  be  concerned 
in  the  tumor  formation,  tliereby  constituting  diffused 
and  lobular,  or  circumscribed,  myzomata.  The  latter 
are  the  more  frequent,  as  limited  portions  of  the  gland 
were  affected  in  six  of  the  ten  instances  '  which  I 
have  collated.  In  one  of  these,  as  occurs  also  in  fibro- 
ma and  sarcoma,  the  gro^vth,  which  was  as  large  as 
an  orange,  displaced  the  gland  backward,  but  was 
attached  to  it  by  a  pedicle  of  the  thickness  of  two 
fingers.  In  the  remainder,  the  tumor  was  merely 
encapsuled,  without  being  fixed  to  the  mamma.  In 
both  forms  the  lacteal  glands  usuaEy  disappear ;  but 

'  The  cases  are  recorded  by  De  Morgnn,  Trans.  Path.  Soc.  London,  vol.  xx, 
p.  360;  Cooke,  Ibid.,  vol.  xix,  p.  398  ;  Pean,  De  La  Forciprcssurc,  p.  41,  and 
Lefom  de  Clinigue  Chir.,  p.  478 ;  Labbe  and  Covne,  op.  cit.,  pp.  322  and  326 ; 
Moore,  Dublin  Journ.  of  Med.  Science,  vol.  Ixiii,  p.  489 ;  Virchow,  op.  cit.,  p. 
427  ;  Cornil  and  Kanvier,  op.  cit.,  p.  1162  ;  and  Barton,  ante. 


MYXOMA.  105 

in  one-half  of  all  examples  tlie  dilated  ducts  are  filled 
with  vegetations,  and  constitute  the  intracanalicular 
variety  of  myxoma. 

Mucous  tumors  are  solitary,  round,  or  ovoid,  oc- 
casionally lobulated,  and  are  usually  seated  in  the 
upper  hemisphere  of  the  breast,  and  toward  its  outer 
periphery.  They  are  quite  liable  to  inflammation, 
ulceration,  and  fungous  protrusion,  as  those  accidents 
were  met  with  in  three  of  the  seven  examples  in 
which  the  histories  are  complete.  In  one  of  Pean's 
cases,  the  tumor,  which  had  existed  for  fourteen  years 
in  a  woman  aged  fifty -five,  had  been  the  seat  of  a 
superficial  abscess  for  six  weeks.  In  one  described 
by  Labbe  and  Coyne,  the  intracanalicular  growth  pro- 
truded through  an  opening  in  the  skin  in  the  form  of 
a  bleeding  black  mass,  and  was  the  seat  of  occasional 
slight  hemorrhage.  In  this  instance  the  ulceration 
was  due  to  specific  infiltration  of  the  skin,  as  the 
papillae  were  much  enlarged,  and  composed  of  myxo- 
matous tissue.  In  the  case  of  telangiectatic  lipoma- 
tous  tumor,  recorded  by  Moore,  ulceration  ensued  in 
five  years,  and  the  patient  nearly  bled  to  death.  Dur- 
ing the  last  twelve  months  of  its  existence,  it  bled  at 
each  menstnial  period,  and  the  hemorrhage  was  quite 
profuse  one  month  before  its  removal,  after  which  it 
discharged  gelatinous  material. 

Myxomata  develop  as  early  as  the  twenty-ninth 
and  as  late  as  the  fifty-sixth  year,  the  average  being  the 
forty-sixth  year.     Of  7  cases, 

0  appeared  between  10  and  20  years. 

1  "  "  20  "  30  " 
0  "  "  30  "  40  " 
4  "  "  40  "  50  " 

2  "  "  50  "  GO  " 


106  GROWTH. 

Hence,  as  sixtli-seventlis  of  tlie  entire  number  ap- 
pear during  the  functional  decline  of  the  mamma, 
their  evolution,  like  that  of  carcinoma,  is  intimately 
connected  with  the  period  of  obsolescence  of  the 
breast,  or  when  the  glandular  stiiicture  is  disappear- 
ing and  the  fibrous  and  fatty  constituents  predomi- 
nate. 

Three  of  the  women,  of  whom  one  was  sterile  and 
two  were  multiparous,  were  married,  and  one  was 
single,  the  social  condition  not  being  noted  in  the 
remainder.  In  one  the  tumor  appeared  seven  years 
after  the  menopause,  which  occurred  at  the  age  of 
forty-seven ;  in  one  at  the  seventh  month  of  the  first 
pregnancy,  and  the  menses  were  regular ;  while  in  one 
the  catamenia  were  irregular  at  the  age  of  forty-nine. 
In  not  a  single  instance  was  the  manifestation  of  the 
growth  referable  to  trauma  or  heredity. 

Myxomata  increase  more  rapidly  than  fibromata, 
but  less  swiftly  than  sarcomata,  although  their  volume 
is  never  so  great  as  is  met  with  in  those  neoplasms. 
Even  when  the  entire  gland  is  involved,  it  is  unusual 
for  them  to  attain  the  size  of  a  child's  head,  as  in 
the  tumor  depicted  by  Virchow.  In  a  general  way  it 
may  be  said  that  they  grow  rapidly,  since,  with  the 
exception  of  one  which  had  acquired  the  volume  of  a 
walnut  in  six  months,  none  are  recorded  of  less  size 
than  an  apple  or  an  orange  within  the  first  year  of 
their  existence,  while  one  measured  three  inches  and 
a  half  by  two  inches  and  a  quarter  in  that  time.  In 
the  case  of  Moore  a  weight  of  upward  of  five  pounds 
was  reached  in  six  years. 

While  they  evince  no  disposition  whatever  to  ex- 
tend to  the  deeper  structures,  they  invade  the  skin 


MYXOMA.  107 

in  iiye-eiglitlis  of  all  instances,  as  was  sliown  by  its 
positive  infiltration  in  two  cases,  and  by  discolora- 
tion and  adliesion  in  tkree.  Among  these  five  exam- 
ples ulceration  bad  also  occurred  in  two.  Enlarge- 
ment, without  however  indui'atiou,  of  the  associated 
lymphatic  glands  was  observed  in  only  one  of  the 
eight  cases  in  which  the  symptoms  are  detailed, 
but,  as  they  were  not  interfered  vnth,  and  as  the 
further  history  of  the  case  after  operation  is  incom- 
plete, it  is  impossible  to  say  what  changes  they  had 
undergone. 

Of  the  natural  course  of  myxoma,  nothing  is 
known,  as  all  the  cases  were  subjected  to  the  knife. 
Of  eight  examples,  in  which  there  are  more  or  less 
finished  accounts,  one  died  from  the  effects  of  the 
operation,  the  tumor  having  existed  for  one  year ;  one 
was  well  two  months  subsequently,  and  the  gi^owth 
was  of  twelve  months'  duration ;  two  were  well,  mth- 
out  recurrence,  at  the  end,  respectively,  of  eighteen  and 
twenty-six  months ;  one  recurred  in  fifteen  months, 
and  was  still  living  three  years  and  a  half  from  the 
first  appearance  of  the  disease  ;  while  thi'ee  were  de- 
void of  further  histories,  but  in  these  the  disease  had 
existed,  respectively,  six  months,  six  years,  and  four- 
teen years  before  removal.  In  these  eight  examples 
the  duration  of  life,  from  the  first  observation  of  the 
disease  until  its  termination  in  recoveiy  or  death, 
varied  from  six  months  to  fourteen  years,  and  aver- 
aged forty-five  months.  Excluding  the  cases  in  which 
the  history  terminates  with  recovery  from  opera- 
tion, there  was  one  recurrence  out  of  three  opera- 
tions. Hence,  it  may  be  said  that  myxomata  are 
tumors  of  limited  malignity,  as  they  recur  in  33  per 


108  DIAGNOSIS. 

cent,  of  all  instances,  but  do  not  occasion  metastatic 
deposits.' 

The  clinical  features  of  mucous  tumor  are  by  no 
means  characteristic.  The  great  softness  and  frequent 
sensation  of  fluctuation,  which  distinguish  it  in 
other  situations,  and  through  which  it  is  liable  to  be 
confounded  with  fatty  and  cystic  growths,  are  ab- 
sent in  the  majority  of  cases  in  this  locality.  Of  the 
five  examples  in  which  the  consistence  is  noted,  in 
only  two  was  it  soft ;  in  one  it  simulated  a  cyst  mth 
thickened  walls,  or  had  a  doughy  feel  circumscribed 
by  a  firmer  sensation ;  while  in  two  it  was  more  or 
less  hard.  In  three-eighth"  of  all  instances  the  skin 
is  adherent  and  discolored,  while  in  one-fourth  it  is 
ulcerated.     The  axillary  glands  are  enlarged  in  one 

*  As  has  just  been  stated,  myxoma  of  the  mammary  gland,  although  it  recurs 
after  operation  in  one-third  of  all  instances,  does  not  extend  to  the  walls  of  the 
chest,  or  occasion  metastatic  tumors  of  the  viscera.  The  paramammary  form, 
or  that  which  starts  in  the  coverings  of  the  gland,  is  eminently  malignant.  Thus, 
Virchow '  records  one  which  developed  upon  the  breast  from  a  wart  at  the  side 
of  the  nipple  at  the  age  of  nineteen,  and,  in  two  years,  formed  a  polypoid  tumor 
of  the  volume  of  an  infant's  fist;  but  further  details  are  wanting.  Of  the  four 
that  started  in  the  subcutaneous  fat,  that  of  Neumann  "^  recurred  twice,  and  the 
pectoral  muscle  was  the  seat  of  small  tubers ;  that  of  Pcan  ^  recurred  four 
times,  and  the  axillary  glands  were  voluminous,  but  the  patient  remained  well 
ten  months  after  the  last  operation  ;  that  of  Forster  *  invaded  the  mamma  and 
recurred  in  two  months,  and,  on  death  eight  weeks  later,  the  muscles  of  the 
chest  were  involved,  but  the  viscera  were  sound  ;  while  in  that  of  Morris  *  there 
was  one  recurrence,  and,  on  death  in  eighteen  months  from  the  first  observation 
of  the  disease,  the  posterior  part  of  the  right  lobe  of  the  liver  was  found  to  be 
transformed  into  a  myxomatous  mass,  as  large  as  a  foetal  head  at  full  term, 
which  invaded  the  base  of  the  contiguous  lung.  Hence,  of  the  four  cases  of 
paramammary  myxoma,  in  which  there  is  a  further  history  after  operation,  all 
recurred,  and  one  reproduced  itself  in  the  liver. 


'  Op.  cit,  p.  419. 

*  Virchoiv^s  Archiv,  Bd.  xxiv,  p.  316. 
^  Lemons,  etc.,  ante,  p.  4Y8. 

*  Tram.  Path.   Soc.  London,  vol.  xxiii,  p.  260,  and  Guy^s  Hosp.  Heps.,  ser. 
3,  vol.  xviii,  p.  48. 

*  Ibid.,  vol.  xxiii,  p.  274,  and  vol.  xxiv,  p.  120, 


MYXOMA.  109 

case  out  of  every  eiglit,  but  tlie  nipple  and  veins  are 
normal,  and  tlie  tumor  is  mobile  on  tlie  cliest.  In 
four-seventlis  of  the  cases  tlie  patient  experiences 
pain,  whicli  will  be  found  to  be  slight  in  one,  and 
lancinating,  although  intermittent,  in  three. 

Some  of  these  signs,  when  considered  in  connec- 
tion with  the  mature  age  at  which  the  growth  usually 
develops,  tend  to  render  the  diagnosis  most  obscure. 
Thus,  in  the  case  of  De  Morgan,  which  occurred  at  the 
age  of  fifty-six,  the  enlarged  axillary  glands,  slightly 
adherent  shin,  and  firm  feel  of  the  tumor  caused  it 
to  simulate  carcinoma. 

On  the  whole,  a  solitary,  rapidly  and  continuous- 
ly growing,  although  not  bulky,  round  or  ovoid,  pain- 
ful, soft,  or  rather  firm  tumor,  vdth  limited  attach- 
ment to  the  skin,  but  movable  on  the  deeper  struc- 
tures, with  a  tendency  to  ulcerate,  and,  it  may  be,  to 
discharge  a  gelatinous  material,  but  unattended  with 
enlargement  of  the  glands  or  superficial  veins,  or  re- 
traction of,  or  discharge  from,  the  nipple,  and  occur- 
ring at  about  the  forty-sixth  year,  may  be  assumed  to 
be  a  myxoma. 


CHAPTEK    YIII. 

In  speaking  of  the  connective  tissue  neoplasms,  I 
drew  attention  to  tlie  fact  tliat  tlie  glandular  appa- 
ratus of  the  mamma  was  liable  to  undergo  certain 
changes,  such  as  enlargement  of  the  acini  and  iiTita- 
tive  hypei-plasia  of  the  epithelium,  which  so  thor- 
oughly impressed  the  older  writers  with  the  idea  that 
they  were  the  essential  elements  as  to  lead  them  to 
regard  the  tumors  in  which  they  were  found  as  being 
composed  of  glands  of  new  foiTQation,  and  to  lose 
sight  of  the  stroma  as  their  j)ossible  matricular  tissue. 
Hence,  under  the  term  adenoma,  or  some  of  its  anti- 
quated synonyms,  as  tumeur  adenoide,  hypertrophic 
partielle,  adenocele,  or  mammary  glandular  tumor, 
Birkett,  Broca,  Velpeau,  Lebert,  Bryant,  and  Paget, 
and  more  recently  Cadiat  and  Lannelongue,  de- 
scribed gro^\i;hs  which  they  regarded  as  being  true 
adenoma,  but  which  differ  from  that  neoplasm  in 
their  genesis,  intimate  nature,  and  clinical  features, 
and  which  are  composed,  for  the  most  part,  of  trans- 
formed preexisting  lacteal  glands  contained,  but 
widely  separated,  in  a  fibrous  stroma. 

With  the  exception  of  myxoma,  there  is  not  a 
single  neoplasm  which  is  so  uncommon  as  genuine 
adenoma,  since  it  was  met  with,  as  I  have  pointed  out 


ADENOMA.  Ill 

at  page  9,  only  twice  out  of  six  hundred  and  forty- 
nine  tumors  of  the  breast.  During  the  past  year  I 
examined  and  described  four  specimens '  from  the 
practice  of  other  surgeons,  and  reported  a  case  of  my 
own,  and  have  collated  thirteen  additional  examples, 
which  serve  as  the  materials  at  my  disposal  for  ^vrit- 
ing  the  life  history  and  histology  of  this  little  under- 
stood foimation. 

The  physiological  type  of  adenoma  is  to  be  found 
in  a  mamma  preparing  for  lactation.  During  the  first 
pregnancy,  and  toward  its  termination,  the  glandular 
structure  proliferates,  through  which  there  is  a  new 
growth  of  acini  and  ducts  throughout  the  organ ; 
these  are  contained  in  a  vascular,  succulent,  loose, 
and  comparatively  sparse  connective  tissue,  which  is, 
moreover,  rich  in  cellular  elements.  Pathologically, 
a  new  formation  of  lacteal  glands  takes  place  through 
a  process  of  budding  and  extension  into  the  propor- 
tionately scant  interstitial  stroma,  as  is  shown  in  fig. 
16,  so  that  they  preponderate,  and  represent  a  simple 
h}^3erplasia  of  the  glands  as  a  whole,  and  not  merely 
of  their  investing  epithelium,  as  is  taught  by  most 
authors.  A  neoplasm  which  presents  a  likeness  to 
the  mamma  of  a  female  advanced  in  gestation  may  be 
styled  a  typical  adenoma,  as  is  represented  in  fig. 
14;'  but  it  is  only  a  partial  likeness,  as  the  efforts  of 
nature  appear  to  be  confined  to  the  excessive  produc- 

'  Amer.  Jour.  Med.  Sciences,  October,  1879,  p.  459,  and  Fhil.  Med.  Times, 
January  31,  1880,  p.  218. 

*  From  a  growth,  which  is  numbered  6,755,  surgical  section  of  the  Army 
Medical  Museum,  and  which  was  enucleated  from  the  upper  portion  of  the 
mamma  of  a  mulatto,  sixteen  years  of  age,  by  Dr.  Peter,  of  Georgetown,  D.  C. 
The  tumor  was  of  three  months'  duration,  was  ovoid  and  nodulated,  and  mea- 
sured one  inch  and  three  quarters  in  length  by  one  inch  and  a  quarter  in 
breadth.     At  the  expiration  of  twenty-eight  months  there  was  no  recurrence. 


112 


ANATOMY. 


tion  of  glandular  apparatus,  without  attempting  to 
unite  tlie  acini  into  distinct  lobules  attached  to  excre- 
tory ducts.     The  criterion  of   adenoma  is  the  pres- 


FiG.  14. 


Tubular  Adenoma. — Allowing  principally  transverse  sections  of  newly  formed 
ducts.  The  epithelium,  which  is  merely  represented  by  the  stained  nuclei, 
is  separated  from  the  intertubular  connective  by  the  membrana  propria. 
To  the  left  of  the  figure  a  more  highly  magnified  duct  is  shown,  and  its 
cuboidal  epithelium  is  seen  to  rest  upon  the  subepithelial  layer  of  the  thia 
endothelial  cells  of  the  limiting  membrane. 

ence  of  the  membrana  proj^ria,  which  separates  the  in- 
vesting epithelium  from  the  surrounding  connective. 
When  it  is  broken  through,  and  the  epithelium  grows 
as  solid  plugs  into  the  stroma,  the  tumor  ceases  to  be 
an  adenoma  and  becomes  a  carcinoma. 

Typical  adenoma  is  so  rare  that  of  the  five  cases 
which  I  examined  the  one  represented  in  the  above 
figure  is  the  only  one  that  I  have  seen.  Cornil  and 
Ranvier,*  Waldeyer,'  Llicke,"  Foerster,*  and  Wilks 
and  Moxon/  however,  evidently  met  with  it,  as  they 

»  Op.  cit.,  p.  291. 

'  Virchow's  Archiv,  Bd.  xli,  p.  516. 

'  Hdbck.  der  AUg.  und  Spec.  Chirnrgie,  Bd.  ii,  Abth.  1,  Heft  2,  p.  280. 

*  Op.  cit.,  Bd.  ii,  p.  480. 

*  Led.  on  Path.  Atiat.,  p.  583.  v 


ADENOMA.  113 

refer  to  tumors  in  wliich  tlie  newly  formed  acini, 
along  Avitli  their  epitlielium,  preserve  their  natural 
form  and  size,  are  provided  wdth  a  central  lumen, 
and  are  contained  in  a  relatively  small  amount  of 
connective  tissue ;  and  this  description  agrees  with 
that  of  Deifaux,'  excepting  that  he  states  that  the 
acini  are  greatly  dilated. 

From  the  marked  tendency  which  adenoma  has  to 
undergo  cystic  changes,  it  usually  presents  itself  as 
an  atypical  growth,  which  is  characterized  by  altera- 
tions in  the  shape,  dimensions,  and  grouping  of  the 
enlarged  and  deformed  glands,  but  in  which  the 
membrana  propria  is  preserved.  Thus,  nearly  five 
years  ago  I  removed  fi'om  the  upper  and  inner  cir- 
cumference of  the  breast  of  a  prolific  married  woman, 
forty-six  years  of  age,  a  tumor  of  three  years'  dura- 
tion, which  was  hard,  perfectly  mobile,  bossed,  almost 
spherical,  of  the  volume  of  a  walnut,  and  unattended 
with  pain,  tenderness,  or  changes  in  the  skin,  nipple, 
veins,  or  axillary  glands.  On  section,  the  white,  but 
here  and  there  rosaceous-white,  basis  was  dotted,  but 
not  to  any  considerable  extent,  with  cavities,  of  which 
none  were  larger  than  a  small  pea,  which  were  filled 
with  a  yellowish  pultaceous  or  atheromatous  material 
that  could  be  expressed  as  plugs.  Under  the  micro- 
scope, the  greatly  enlarged  acini  were  seen  to  be 
packed,  for  the  most  part,  with  large,  round,  angular, 
elongated,  and  polyhedral  cells,  which  had  undergone 
fatty  degeneration  in  the  centre  of  the  largest  acini. 
The  connective  tissue  was  present  in  much  less  abun- 
dance than  I  have  ever  witnessed  it  in  a  lactating 
mamma,  and  it  was  in  parts  the  seat  of  small-celled 

*  Confrib.  d  VStude  dcs  Tumeurs  du  Sein  d'Origine  £pitheliale,  p.  17. 

8 


114 


AI^ATOMY. 


infiltration.  Altliougli  tlie  dilatation  of  the  acini  was 
similar  to  tliat  of  tlie  secreting  breast,  tlie  atypical 
grouping  of  tlie  large  and  defoimed  cells  served  to 
distinguish  the  structure  from  that  of  the  functional- 
ly active  mamma,  while  from  the  presence  of  the 
atheromatous  moulds,  and  the  exclusive  enlargement 
of  the  acini,  the  tumor  is  to  be  classed  as  a  cystic 
acinous  adenoma,  the  contents  of  the  cavities  being 
due  to  caseation  of  the  epithelium. 

The  neoplasm  in  question  corresponded  almost 
exactly  to  one  described  by  Billroth,  the  minute 
features  of  which  are  delineated  in  fig.  15,'  from  Rind- 


FiG.  15. 


Cystic  Acinous  Adenoma. — The  acini  are  seen  to  be  greatly  dilated,  and  more 
or  less  closely  packed  with  transformed  epithelium. 

fleisch.      From  its  peculiar  appearances  Billroth  at 
first  called  it  genuine  epithelial  carcinoma,  and  Rind- 

'  From  a  section  of  a  tumor,  as  large  as  a  child's  head,  and  of  twenty-three 
months'  duration,  which  Billroth  removed,  in  1863,  from  a  multipara,  forty-two 
years  of  age.  It  was  preceded  by  a  thin,  bloody  discharge  from  the  nipple,  was 
hard,  lobulated,  mobile  under  the  sound  skin  and  upon  the  chest,  and  not  tender. 
There  were  two  small  indurated  glands  in  the  axilla.  The  patient  died  of  sep- 
ticaemia on  the  seventh  day.  Hdhch.  der  AUg.  und  Spec.  Cldr.,  Bd.-  iii,  Abth. 
2,  p.  63,  and  Langenheck'' s  Archiv,  Bd.  vii,  pp.  860  and  87 li 


ADENOMA.  115 

fleiscli '  regarded  it  as  cancroid  hypertropliy.  From 
tliis  unfortunate  nomenclature  tlie  term  epithelioma 
is  now  used  for  tumors  possessing  tliis  structure  by 
Labbe  and  Coyne,'  Malassez  and  Deffaux,"  and  Du- 
play,*  altliough  Neumann/  Langlians/  Cornil  and 
Ranvier/  Waldeyer/  Klebs,"  and  Liicke  "  adhere  to 
adenoma.  Had  the  French  authors  not  overlooked 
a  subsequent  paper  in  which  Billroth  gives  a  more 
detailed  account  of  his  tumor,  and  calls  it  cystoid 
adenoma,  this  confusion  would  probably  not  have 
arisen.  It  is  to  be  regretted,  as  epithelioma  implies 
the  structure  of  so-called  cancroid  met  with  in  other 
tissues  and  organs.  Even  as  a  generic  term  it  is 
most  objectionable,  unless  carcinoma,  which  is  also  an 
epithelioma  in  the  sense  of  its  arising  from  epithelial 
elements,  be  designated  atypical,  carcinomatous,  or 
infiltrating  epithelioma,  to  distinguish  it  from  adeno- 
ma. Adenoma  would  then  be  regarded  as  typical,  non- 
carcinomatous,  or  circumscribed  epithelioma.  From 
the  fact,  however,  that  the  epithelial  elements  of 
adenoma  may  be,  and  usually  are,  irregular  in  their 
size,  form,  and  arrangement,  and  thus  produce  an  aty- 
pical epithelioma,  which  differs  widely  in  its  struc- 
ture and  life  from  carcinoma,  the  term  had  best  be 
dropped  altogether. 

As  I  have  just  pointed  out,  adenomata  are  usually 
composed  of  enlarged  acini,  with  aberrations  in  the 
characters  of  their  investing  epithelium,  although 
they  may  be    constituted  mainly  of  newly  formed 

'  Op.  cit,  p.  537.  6  Ibid.,  Bd.  Iviii,  p.  147. 

"  Op.  cit.,  p.  333.  '  Op.  cit,  ante. 

'  Op.  cit.,  ante.  8  j^^.  cit.,  ante. 

*  Op.  cit.,  t.  V,  p.  632.  9  Op.  lit,  p.  1201, 

^  Virchow's  Archiv,  BJ.  xxiv,  p.  326.  '°  Op.  cit.,  ante. 


116 


AITATOMY. 


ducts.  When  tlie  acini  predominate,  they  may  be 
termed  acinous;  while  they  may  be  called  tubular 
when  the  ducts  preponderate.    Of  the  eighteen  cases, 


Cystic  Tubflar  Adexoma. — a,  Dilated  and  cystic  acinus,  frfving  off  nine  pro- 
longations, in  the  form  of  tubes  lined  by  columnar  epitlielium,  which  pur- 
sue, as  a  rule,  a  parallel  course,  but  now  and  then  divide  and  anastomose 
with  one  another  and  with  offshoots  from  other  acini,  one  of  which  is  par- 
tially represented  at  h.  The  majority  preserved  their  lumen  throughout, 
although  they  frequently  terminated  in  attenuated,  solid,  cellular  processes, 
which  sometimes  were  turned  upon  themselves.  The  intcrtubular  voung 
connective  tissue  was  so  very  scanty  that,  on  transverse  section,  many  of 
the  closely  crowded  tubules  appeared  to  be  separated  merely  by  their 
adventitia. 


ADENOMA.  117 

eleven  were  cystic  acinous  growtlis.  These  include 
three  recorded  by  Labbe  and  Coyne/  two  by  Fo- 
chier,'  and  one,  respectively,  by  Steudener,'  Neu- 
mann,* Billroth,'  Nancrede,'  Klotz,"  and  myself."  Sev- 
en were  tubular;  two  of  these  are  recorded  by 
Langhans,"  and  one  each  by  Billroth,"  Morton," 
Sloan,"  Peter,"  and  Levis,"  of  which  six  were  cystic. 
Hence  it  appears  that  pure  adenoma  is  very  uncom- 
mon, while  the  cystic  acinous  variety  constitutes  the 
majority;  and  the  cystic  tubular  represents  rather 
more  than  one-half,  of  which  fig.  16  "  is  a  beautiful 
illustration. 

J  Op.  ciL,  pp.  343,  352,  and  356. 
^  Lyon  3Iedicale,  vol.  xiv,  p.  142. 

3  Virchovo's  Arcftiv,  Ed.  xliv,  p.  42. 

4  Ante. 

5  Ante. 

^  Trans.  Path.  Soc.  Phila.,  vol.  vi,  p.  113. 
'  Langenheck's  ArcMv,  Bd.  xxv,  p.  59,  1880. 

*  Amer.  Jour.  Med.  Sciences,  ante. 

^  Ante. 

'"  LangenhecJc's  Archiv.,  Bd.  vii,  p.  861. 

"  Amer.  Jour.  iled.  Sciences,  Oct.,  1869,  p.  462, 

'2  Phila.  Med.  Times,  Jan.  31,  1880,  p.  218. 

13  Ibid. 

"  Ibid.,  p.  217. 

1'  From  a  section  of  an  ulcerated  and  fungating,  moderately  soft,  somewhat 
lobulated  tumor,  of  the  volume  of  a  child's  head,  of  eighteen  years'  duration, 
from  a  spinster  fifty  years  of  age,  which  was  removed  by  Dr.  Morton  at  the 
Pennsylvania  Hospital.  It  had  been  stationary  for  the  first  eight  years,  when 
it  began  to  increase,  and,  at  the  expiration  of  twelve  months,  burst  and  dis- 
charged a  bloody  fluid,  when  it  apparently  disappeared.  At  the  end  of  four 
months,  another  nodule  manifested  itself  immediately  below  the  site  of  the 
previous  one,  which,  in  its  tuni,  at  the  expiration  of  two  years  and  a  half, 
opened,  and  was  the  seat  of  a  constant  discharge,  which  latterly  was  profuse, 
offensive,  and  bloody.  The  nipple  was  retracted,  but  the  axillary  glands  were 
normal.  After  removal,  the  surface  of  the  growth  was  uneven  and  nodular 
from  underlying  cysts,  which  were  filled  with  blood,  and  the  skin  toward  its 
base  had  a  purplish  tint.  The  fungus  had  a  breadth  of  six  inches,  and  the 
numerous  cysts  varied  in  size  from  a  pin's  head  to  a  small  egg,  and  possessed 
thin  and  blood-stained  walls. 


118  DE  GENERA  TIORS. 

Adenoma  differs  from  all  other  neoplasms  of 
tlie  mamma  through  its  wonderful  tendency  to  be- 
come cystic,  seventeen  of  the  entire  number  having 
underarone  that  transformation.  The  contents  of  the 
cysts  may  be  fluid  or  semifluid,  and  are  due  to  changes 
which  ensue  in  the  proliferating  epithelium.  In  the 
former  event,  and  ordinary  fluid  cysts  were  seen  in 
eight  examples,  the  secretion  may  remain  lactescent, 
as  in  the  cases  of  Nancrede  and  Neumann ;  or  may 
be  sanguinolent  from  the  presence  of  vascular  vegeta- 
tions, as  in  one  of  the  cases  recorded  by  Labbe  and 
Coyne ;  or  even  with  the  absence  of  very  large  vege- 
tations, as  in  the  examples  of  Morton  and  Levis. 
When  the  cells  undergo  advanced  fatty  changes,  as 
happened  in  nine  instances,  the  contents  are  of  a 
rather  dense  caseous  or  atheromatous  nature ;  but  the 
cavities  are  usually  minute,  and  never  attain  the  vol- 
ume of  an  egg,  as  is  witnessed  when  the  contents  are 
fluid.  Their  size,  indeed,  rarely  exceeds  that  of  a 
hazel-nut,  and  the  larger  cavities  are  usually  formed 
by  the  confluence,  or  breaking  do^vn,  of  contiguous 
ones.  In  five  of  the  eighteen  specimens,  the  lining 
epithelium  was  proliferating  to  form  microscopic  in- 
traacinous  vegetations  or  papillae,  which  were  purely 
epithelial  in  their  composition  when  they  were  small, 
but  were  made  up  of  delicate  vascular  connective 
tissue,  clad  with  columnar  eiDithelium,  when  they 
completely  filled  the  acini,  as  was  witnessed  in  the 
first  case  observed  by  Billroth. 

With  the  exception  of  cystic  changes,  adenoma 
does  not  appear  to  undergo  other  degenerations,  unless 
it  be  the  telangiectatic,  of  which  the  cases  of  Morton 
and  Levis  are  good  illustrations ;  or  the  myxomatous, 


ADENOMA.  119 

as  in  an  example  of  adenoma  of  tlie  male  mamma, 
which  is  recorded  by  Obolensky/  but  whicli  I  have 
not  included  here.  It  is,  moreover,  rather  liable  to 
spontaneous  ulceration,  as  that  accident  was  met  with 
in  the  four  instances  recorded  by  Fochier,  Morton, 
and  Levis ;  although  it  was  threatened  in  one  de- 
scribed by  Labbe  and  Coyne.  In  another  case,  under 
the  care  of  Labbe,  the  tumor  protruded  fungous 
vegetations  as  a  result  of  injections  of  carbolic  acid, 
and  in  that  of  Sloan  the  fungus  was  excited  by 
lancing;. 

Adenoma  is  usually  ovoid,  and  invariably  bossed 
or  nodulated  in  outline,  but  not  largely  so,  and  of  a 
hard  resistant  consistence,  although,  when  decidedly 
cystic,  it  may  be  uniformly  soft  and  elastic,  or,  as  more 
often  happens,  hard,  except  at  the  larger  bosses  over 
which  it  fluctuates.  Although  it  is  limited  by  a  dis- 
tinct fibrous  capsule,  it  is,  when  of  moderate  volume, 
closely  and  broadly  united  to  or  incoi^^orated  with 
the  mamma ;  but  its  attachment  is  less  cons^^icuous 
as  it  increases  in  bulk.  On  section,  the  cut  surfaces 
are  smooth,  iobed,  of  a  milky-white  color,  with  pos- 
sibly rosaceous  areas,  and  dotted  with  orifices  or 
small  cavities,  to  which,  after  the  expression  of  their 
contents,  is  imparted  a  spongy,  honeycomb,  or  sieve- 
like appearance.  Now  and  then  they  are  occupied 
by  fluid  cysts,  which,  however,  rarely  number  more 
than  three  or  four,  are  usually  quite  small,  and  rarely 
exceed  the  volume  of  a  w^alnut.  They  are  never 
pen^aded  by  fissures  or  slits,  nor  are  they  the  seat 
of  dilated  ducts  with  intracanalicular  solid  growths, 
such  as  are  witnessed  in  the  connective  tissue  neo- 

'  Virchoio-HirscJi's  Jahrcshcricht,  Bd.  i,  p.  305. 


120  ETIOLOGY. 

plasms,  or  of  yellowisli  lines  or  spots,  sucli  as  are 
seen  in  carcinoma. 

Adenoma  is  always  solitary,  and  generally  ori- 
ginates toward  the  upper  and  inner  circumference  of 
tlie  mamma,  being  found  either  beneath  or  in  the 
vicinity  of  the  nipx3le  in  only  one-third  of  all  in- 
stances. It  develops  as  early  as  the  sixteenth  and  as 
late  as  the  fifty-ninth  year,  the  average  age  of  its  first 
observation  being  thirty-four  years.  Of  the  18  ex- 
amples, 

2  appeared  between  10  and  20  years. 


4 

(( 

(( 

20 

"    30 

6 

u 

u 

30 

"    40 

5 

u 

u 

40 

"    50 

1 

(( 

(( 

60 

"    60 

Of  the  entire  number,  not  a  single  one  occurred  before 
the  sixteenth  year,  or  during  the  developmental  state 
of  the  mamma ;  twelve,  or  66'66  per  cent.,  appeared 
previous  to  the  fortieth  year,  or  during  the  period  of 
the  greatest  functional  activity  of  the  breast;  and 
six,  or  33*33  per  cent.,  after  that  age,  or  during  the 
functional  decline  of  the  gland.  Eleven  of  the  pa- 
tients were  married  when  the  tumor  was  first  de- 
tected, four  were  single,  and  in  three  the  social  con- 
dition is  not  stated.  Of  the  married  women,  six  were 
multiparous,  two  had  one  child,  two  were  barren,  and 
the  question  of  children  is  not  mentioned  in  one.  In 
none  did  the  neoplasm  originate  during  lactation. 
The  menstrual  discharge  was  regular  in  all  of  the 
cases  in  Avhich  that  function  is  noted.  In  one  in- 
stance the  disease  was  presumed  to  depend  upon  a 
puncture  by  a  needle,  and  in  one  upon  a  blow ;  in 
none  was  it  traceable  to  hereditary  influence ;  in  one, 
it  was  preceded  by  eczema  of,  and  a  milky  discharge 


ADENOMA.  121 

from,  the  nipple  on  the  removal  of  the  crusts,  which 
had,  however,  ceased  for  nine  years ;  and  in  one  by 
mammary  abscess.  The  general  health  of  the  sub- 
jects was  excellent. 

The  increase  of  adenoma  is,  upon  the  whole,  less 
rapid  than  that  of  any  other  of  the  neoplasms  of  the 
breast,  and  is  not  influenced  by  lactation,  pregnancy, 
or  uterine  disorders.  In  my  own  case  the  tumor 
attained  the  volimie  of  a  walnut  in  three  years,  while 
in  that  of  Peter  it  grew  to  the  same  dimensions  in 
three  months ;  and  in  three  cases  it  was  as  large  as 
a  hen's  Qgg  in  two,  six,  and  twelve  months.  Certain 
writers  state  that  it  does  not  exceed  the  latter  volume, 
but  it  may  reach  the  size  of  a  fist  in  two,  fifteen,  or 
thirty-six  years,  or  of  a  child's  head  in  ten  months, 
twenty-three  months,  or  eighteen  years.  Hence  the 
rate  of  growth  is  very  variable,  but  the  mode  of 
growth  is  peculiar  in  being  equable  and  uninter- 
rupted. As  a  rule,  the  increase  is  so  slow  that  many 
years  may  elapse  before  the  tumor  attains  even  a  mod- 
erate bulk.  Thus  in  the  case  of  Morton,  and  in  one  of 
Labbe's,  it  was  scarcely  appreciable  for,  respectively, 
seven  and  ten  years ;  while  in  another  of  Labbe's  it 
was  so  excessively  gradual  that  the  almond-sized  no- 
dule required  thirty-three  years  to  reach  the  volume 
of  an  egg,  after  which  it  took  on  so  rapid  a  growth 
that  in  three  years  it  equalled  the  dimensions  of  a 
fist.  The  mode  of  increase  appears  also  to  be  singular 
in  that  it  goes  on  by  the  apposition  of  new  nodules  to 
the  original  tuber ;  this  is  due  to  the  successive  in- 
volvement of  contio-uous  nodules,  throuo;h  which  the 
entire  mamma  may  be  converted  into  a  bossed  tumor. 

During  its  further  progress  adenoma  evinces  cer- 


122  PROGNOSIS. 

tain  signs  wliicli,  if  tliey  are  not  carefully  studied,  ren- 
der it  liable  to  be  confounded  witL.  sarcoma  and 
carcinoma.  Thus,  out  of  tlie  sixteen  cases  in  wbicli 
the  histories  are  complete,  the  subcutaneous  veins 
were  prominent  in  one ;  the  skin  was  discolored  in 
four,  and  it  was  adherent  in  six;  the  nipple  was 
sunken,  rather  than  retracted,  in  two,  and  a  bloody 
or  lactescent  discharge  from  that  body  preceded  the 
detection  of  the  tumor  iu  four ;  ulceration  occurred 
late  in  the  disease  in  four,  and  in  two  of  these  a  red, 
vegetating,  and  bleeding  fungus  protinided  through, 
without  being  attached  to  the  mai-gins  of,  the  ulcer ; 
and  in  two  the  axillaiy  glands  were  enlarged  from  irri- 
tative hyperplasia.  In  63-33  per  cent,  of  all  cases 
there  is  absolute  freedom  from  pain ;  in  9  per  cent, 
the  suifering  is  moderate ;  while  in  2  7 '6 7  })er  cent,  the 
pain  is  severe  and  lancinating,  especially  when  the 
growth  has  been  rapid. 

Our  knowledge  of  the  prognosis  of  adenoma  is 
Tinsatisfactoiy.  In  one  of  Fochier's  patients,  the 
parts  were  perfectly  sound  six  months  after  opera- 
tion. In  the  case  of  Peter  there  was  no  return  in 
twenty-eight  months ;  and  in  that  of  Sloan  the  woman 
was  free  from  recurrence  at  the  end  of  two  years. 
One  of  Billroth's  patients  remained  well  for  two  years 
after  the  enucleation  of  a  tubular  adenoma,  but 
there  were  several  large  and  hard  lobules  in  the 
vicinity  of  the  cicatrix.  In  one  of  Labbe's  cases 
local  recurrence  and  enlargement  of  the  axillary  glands 
occurred  in  less  than  twelve  months,  and  death  en- 
sued at  the  expiration  of  three  years  after  the  re- 
moval of  the  entire  breast,  but  there  was  no  post- 
mortem inspection  of  the  body.     The  disease  repro- 


ADENOMA.  123 

duced  itself  in  tlie  cicatrix  in  seven  months  after 
extii'pation  of  tlie  entire  mamma  of  tlie  patient  of 
Steudener,  but  she  was  well  thirty-one  months  after 
its  removal.  Of  the  remaining  twelve,  two  are  entire- 
ly devoid  of  a  histoiy  of  the  teiTnination,  while  seven 
recovered  from  operation,  and  three  died  from  its 
effects.  Hence  adenoma  recurs  in  one-half  of  all 
cases  after  operation,  but  there  is  no  evidence  to  show 
that  it  infects  distant  organs.  The  relatively  benign 
nature  of  the  disease  is,  moreover,  demonstrated  by 
the  fact  that  it  had  existed,  on  an  average,  nine  years 
before  extii'pation,  without  aifecting  the  general 
health.  One  case,  indeed,  was  of  nine,  one  of  fifteen, 
two  of  eighteen,  and  one  of  thirty-six  years'  standing. 
A  small  adenoma  is  veiy  liable  to  be  confounded 
with  a  small  fibroma,  but  the  latter  is  more  dis- 
tinctly circumscribed  and  isolable,  and  far  more  mo- 
bile in  or  upon  the  mamma,  and  its  outline  is  not  so 
decidedly  bossed.  Upon  the  whole,  the  diagnosis  of 
adenoma  is  based  upon  its  hard  and  heavy  feel,  its 
nodular  outline,  its  pretty  intimate  attachment  to  the 
breast  when  of  moderate  volume,  its  mobility  upon 
the  chest,  its  slow  and  equable  growth,  its  increase  by 
the  addition  of  small,  compact  nodules,  its  occurrence 
in  marned  and  prolific  women  toward  the  thirty-fifth 
year,  the  limited  discoloration  and  adhesion  of  the 
sMn  and  ulceration  late  in  the  disease,  and  freedom 
from  retraction  of  the  nipple,  enlargement  of  the  sub- 
cutaneous veins,  and  involvement  of  the  lymphatic 
glands.  If  a  tumor  which  presents  these  features 
has  been  preceded  by  a  discharge  from  the  nipple, 
there  should  be  little  difficulty  in  aniving  at  a  correct 
conclusion  as  to  its  true  nature. 


CHAPTEK  IX. 


CAECIXOMA. 


The  term  carcinoma,  wliicli  is  synonymous  witli 
carcinomatous  epithelioma  and  cancer/  is  applied  to 
an  infiltrating  atypical  epithelial  new  formation,  that 
is  characterized,  clinically,  by  local  infection  of  the 
adjacent  tissues  and  associated  tymphatic  glands,  and 
by  its  marked  tendency  to  general  dissemination.  A 
tumor  which  comprises  these  malignant  attributes 
consists,  structurally,  of  a  cavernous  fibrous  stroma  or 
framework,  the  meshes  or  alveoli  of  which  are  occu- 
pied by  solid  nests,  plugs,  or  cylinders  composed  of 
loosely -heaped  polymorphous  epithelial  cells ;  these 
cells  are  suspended  in  a  serous  fluid,  mthout,  how- 
ever, the  intervention  of  a  cementing  intercellular  sub- 
stance. 

In  addition  to  carcinoma,  adenoma  and  a  variety 
of  sarcoma  possess  an  alveolar  stroma  filled  mth  cells, 
so  that  a  hasty  examination  of  thin  sections  may 
lead  to  confounding  these  three  classes  of  neoplasms. 
In  typical  adenoma  the  dilated  lacteal  glands,  which 
constitute  the  alveoli,  are  lined  by  a  single  layer  of 

'  The  word  cancer  is  employed  by  the  maiority  of  Enjrlish  writers  as  the 
equivalent  of  malignant ;  but  it  is  used  here,  interchangeably  with  carcinoma, 
to  express  anatomical,  and  not  clinical,  features.  There  are  other  tumors  of  the 
breast  which  are  nearly  as  malignant  as  carcinoma,  or  cancer,  but  which  present 
no  structural  likeness  whatever  to  it. 


CARCINOMA.  125 

cuboid  or  columnar  epitlielial  cells  tliat  rest  upon  the 
intact  membrana  propria.  Hence  tlie  cell-cylinders 
are  hollow,  or  provided  with  a  central  lumen,  and  they 
do  not  infiltrate  the  connective  tissue  framework  of 
the  gland.  In  carcinoma,  on  the  other  hand,  the  epi- 
thelial plugs  are  solid  ;  the  membrana  propria  is  de- 
stroyed, and  the  lymph  spaces  of  the  connective  are 
infiltrated  by  the  advancing  cell-cylinders  or  processes. 
In  atypical  adenoma  the  acini  are  enlarged  and  packed 
with  multifoiTQ  epithelial  cells;  but  the  latter  also 
rest  upon  the  membrana  propria,  through  which  in- 
filtration of  the  periacinous  connective  is  prevented. 
The  presence  of  the  membrana  propria  serves,  there- 
fore, to  differentiate  adenoma  from  carcinoma.  In 
alveolar  sarcoma  the  cells  are  of  the  connective  tissue 
type,  pretty  uniform  in  shape  and  size,  and  intimately 
united  with  one  another  and  with  the  walls  of  the 
alveoli  by  intercellular  substance,  so  that  the  cells 
and  stroma  are  interwoven  into  a  single  tissue,  instead 
of  being  easily  separable  into  two  distinct  tissues,  as 
happens  in  carcinoma.' 

Although  an  alveolar  fibrous  stroma  is  so  impor- 
tant a  constituent  of  carcinoma  that  Cornil  and  Ran- 
vier "  declare  that  carcinoma  should  more  appropriate- 
ly be  termed  alveolar  fibroma,  it  is  not,  of  itself,  any 
more  than  are  the  aggregations  of  cells  a  sufiacient 
basis  for  histolog-ical  diao-nosis.  The  stroma,  which 
represents,  partly,  tlie  original  framework  of  the 
mamma,  and,  to  a  greater  extent,  newly  formed  con- 
nective tissue,  is  denser  than  that  found  in  adenoma 
and  sarcoma,  but  differs  in  stiiicture  and  abundance 
in  the  varieties  of  carcinoma.     Many  of  the  alveoli 

'  See  page  68.  «  Op.  cit.,  p.  111. 


126  DEVELOPMENT. 

of  tlie  latter  are,  moreover,  unlike  what  happens  in 
adenoma  and  sarcoma,  lined  by  the  endothelial  cells 
of  the  l}Tnph  spaces  into  which  the  carcinomatous 
plugs  have  groA\Ti.  The  cells  are  not  endowed  wdth 
specific  characteristics.  There  are  no  such  elements 
as  "  cancer  cells  " ;  they  are  merely  enlarged  and  de- 
foiTQed  epithelial  cells,  many  of  which  possess  multi- 
ple nuclei,  and  are  very  prone  to  undergo  fatty  de- 
generation. Hence,  the  determination  of  carcinoma 
depends  upon  the  combined  characters  of  the  cells 
and  stroma  and  their  mutual  arrangement. 

The  histogenesis  of  cancer,  as  I  have  sll0^^^l  in 
Chapter  II,  is  still  the  subject  of  much  dispute ;  but 
I  am  convinced,  from  examinations  of  numerous  sec- 
tions of  at  least  one  hundred  specimens,  that  the  ex- 
clusive view  of  AValdeyer '  as  to  its  derivation  from  the 
glandular  apparatus  is  correct.  Thus,  in  sections  made 
from  the  peripheral  or  developing  zone,  the  acini,  and, 
occasionally,  the  ducts  are  seen  to  be  enlarged,  de- 
formed, and  more  or  less  completely  filled  with  prolif- 
erating epithelium,  and  to  be  surrounded  by  the  m'em- 
brana  propria.  The  periacinous  connective  tissue  is,  at 
the  same  time,  infiltrated  by  lymphoid  cells,  so  that  the 
entire  picture  resembles  an  irritative  or  chronic  in- 
flammatory process,  and  is  very  similar  to  what  I  have 
already  described  as  atypical  adenoma.  During  the 
second  stas-e  the  small-celled  infiltrate  leads  to  the 
new  foimation  of  connective  tissue,  while  further 
alterations  ensue  in  the  shape  of  the  acini,  the  epithe- 
lial cells  change  their  characters,  and  the  membrana 
propria  disappears.  In  the  final  stage,  or  when  the 
development  is  complete,  the  acini,  as  is  represented 

'  Vircliow''s  Archiv,  Bd.  xli,  p.  478. 


CARCINOMA. 


127 


in  fig.   17/  have  extended  or   grown  into  tlie  new 
connective  tissue  and  tlie  preexisting  lympli  spaces  as 


if  s^  reduced  one-half. 

Development  of  Carcinoma. — a,  5,  c,  enlarged  acini,  more  or  less  closely  packed 
with  polymorphous  cells,  the  undermost  layer  of  which  is  columnar.  At  h 
the  membrana  propria  is  intact,  while  at  a  and  f,  below  and  to  the  right,  it 
has  disappeared,  and  the  cells  are  extending  into  the  stroma.  The  connec- 
tive tissue  framework  is  pervaded  by  variously  shaped,  simple  or  branched, 
solid  cell-cylinders,  which  are  the  outgrowths  of  other  acini.  The  cells 
themselves  are  merely  indicated  by  their  stained  nuclei. 

solid,  round,  oval,  or  brancliing  cylinders,  plugs,  or 
bodies,  whereby  the  normal  appearance  of  the  mam- 
mary gland  is  destroyed. 

'  From  a  section  of  a  tubular  scirrhus,  of  one  year's  duration,  which  was 
removed,  along  with  two  enlarged  axillary  glands,  by  Professor  Gross  from  a 
German  fifty-nine  years  of  age.  The  disease  was  preceded  by  psoriasis  of  the 
nipple,  and  recurred  in  the  axilla  in  five  months.  Nearly  five  months  subse- 
quently I  removed  the  axillary  growth,  which  was  as  large  as  an  egg,  and  was 


128  DEVELOPMENT. 

In  none  of  tlie  numerous  sections  wMcli  I  have 
examined  liave  I  ever  been  able  to  detect  tlie  multi- 
plication of  the  endothelial  cells  of  the  stroma ;  nor 
am  I  a  believer  in  the  transformation  of  the  cells  of 
other  tissues  or  organs,  in  which  secondary  or  metas- 
tatic tumors  are  found,  by  contact  with  the  epithelial 
elements  of  the  original  growth  through  some  myste- 
rious ''  action  de  presence,"  or  "  spermatic  influence." 
Although  the  tubers  or  nodules  in  the  skin  and  pec- 
toral muscle,  which  indicate  regional  dissemination, 
may  be  due  to  the  extension  of  the  disease  by  the 
lymphatic  vessels,  as  has  been  demonstrated  by  Lang- 
hans*  and  "VValdeyer,"  my  own  iuvestigations  have 
convinced  me  that  infection  takes  place  along  the 
perivascular  lymph-sheaths.  In  not  a  single  instance 
of  sections  made  from  nodules  seated  in  the  adjacent 
structures  have  I  witnessed  the  extension  of  epithe- 
lial cells  beyond  the  limits  of  the  Ipnphatic  vessels 
to  form  the  tubers.  On  the  other  hand,  I  have  never 
failed  to  discover,  as  is  shown  in  fig.  18,"  that  the 
lymphatic  sheaths  of  the  bloodvessels  were  more  or 
less  closely  jDacked  with  young  epithelial  elements, 
through  which  their  lumen  was  frequently  diminished 
or  even  obliterated.  Even  in  those  cases — and  I  have 
examined  three — in  which  the  skin  covering  the  car- 
composed  of  sixteen  glands.  The  history  of  the  case  may  be  found  in  the 
Fhila.  Med.  Times,  July  5,  1879,  p.  484. 

'  Archiv  fur  Gi/ncek-ologie,  Bd.  viii,  p.  181. 

^  Virchow^s  Archiv,  Bd.  xli,  p.  485. 

^  From  a  section  of  a  nodule  of  the  pectoral  muscle,  which  I  extirpated, 
along  with  an  atrophying  scirrhus,  of  fourteen  years'  duration,  and  a  densely 
hard  axillary  glandular  tumor,  from  a  prolific  married  lady  forty-five  years  of 
age,  on  account  of  severe  suffering.  Her  general  health  was  excellent,  and  she 
still  menstruated.  The  macroscopic  features  of  the  tumor  of  the  mamma  are 
represented  in  fig.  29.  , 


CARCINOMA. 


129 


cinomatous  manima  was  pervaded  by  convex,  elevated 
ridges,  as  large  as  crows'  quills,  and  whicli  conveyed 
to  the  naked  eye  tLe  idea  of  thrombosed  lymphatics, 


Fig.  is. 


Extension  of  Carcinoma  into  the  Great  Pectoral  Muscle. — To  the  left  of  the 
figure  is  seen  a  transverse  section  of  an  artery,  the  upper  portion  of  the 
lymph  sheath  of  which  is  infiltrated  by  epithelial  cells.  The  alveoli  be- 
tween the  primary  muscular  fasciculi  are  due  to  the  absorption  or  disap- 
pearance of  the  greater  portion  of  the  latter  from  the  pressure  exerted 
upon  them  by  the  accumulations  of  cells  in  the  interfascicular  connective 
tissue.  At  several  points  the  muscle  corpuscles  are  seen  to  be  more  abun- 
dant than  is  normal,  but  this  is  an  irritative  phenomenon,  and  there  is  no 
evidence  that  they  participate  in  the  carcinomatous  degeneration.  The  nu- 
clei of  the  cells  alone  are  delineated. 

I  have  only  found  dilated  lymphatics  filled  with  coag- 
ulated lymph. 

The  varieties  of  carcinoma  are  determined  by  the 
9 


130  VARIETIES. 

relative  proportion  of  the  stronia  and  cells,  by  certain 
degenerations  and  transformations,  and  by  the  acci- 
dental formation  of  cysts. 

1.  Fibrous,  or  Coitnective  Tissue,  Caechstoma, 
wliicli  is  equivalent  to  tlie  tubular  form  of  cancer  of 
Billrotli,  and  to  the  clinical  terms  scirrhous,  hard, 
or  chronic  cancer,  includes  ordinary  scirrhus,  simple 
carcinoma,  and  atrophying,  retracting,  withering,  cica- 
trizino:,  or  obsolescent  scuThus. 

a.  In  ordinary  fibrous,  or  scirrhous,  carcinoma,  as  is 
shown  in  fig.  19,'  the  stroma  predominates  over  the 


Fig.  19. 


:i»*^" 


Fibrous,  or  Scirrhous,  Carcinoma. — Showinjr  the  preponderance  of  the  fibril- 
lated  stroma  over  the  collections  of  cells. 

collections  of  cells.  The  trabeculso  of  the  former 
consist  either  of  undulating  connective  tissue,  which 
may  be  rich  or  poor  in  endothelial  cells,  in  accord- 
ance with  the  stage  of  their  development,  or  of  a  non- 
undulating,  faintly  fibrous,  or  entirely  homogeneous 

'  From  a  section  of  a  tumor  of  two  years  and  a  half  duration,  which  I  re- 
moved, along  with  the  entire  breast  and  axillary  glands,  from  a  married  and 
prolific  woman  fifty-seven  years  of  age.  The  skin  over  the  growth  was  occupied 
by  a  few  nodules  ;  the  nipple  was  stiff,  but  not  retracted  ;  and  the  breast  was 
mobile  on  the  pectoral  muscle. 


CARCmOMA. 


131 


and  refracting  tissue.  The  cells  contained  in  the 
alveoli  do  not  attain  tlie  dimensions  of  those  met 
^-ith  in  encephaloid  carcinoma,  nor  are  they  so  liable 
to  fatty  degeneration. 

/3.  SniPLE  Caecinoma,  denominated  fibroso-medul- 
laiy  by  Waldeyer,  stands  midway  between  soft  car- 
cinoma and  ordinary  scirrhus,  the  proportion  between 
the  cells  and  stroma  being  about  equal. 

ry.  In  Atrophyes^g  SciEEnus  the  epithelial  ele- 
ments undergo  fatty  degeneration,  whereby  they  are 
partly  converted   into   a   granular   emulsion,  which 


Fig.  20. 


Atrophying  SciuRmrs.— Showing  fatty  remains  of  cells,  which  would  not  stain, 
contained  in  small  spaces  between  thicli  bundles  of  fibrous  tissue,  trans- 
verse and  oblique  sections  of  which  are  represented  at  two  points. 


is  absorbed,  while  the  contracting  stroma  renders 
the  alveoli  smaller  and  narrower,  so  that  they  are 
merely  represented  by  a  few  elongated  or  fusiform 
clefts,    as   in  tig.  20,'  between  the  thick  tendinous 

'  From  a  section  through  the  centre  of  a  greatly  shrunken  and  discoid  and 
slightly  ulcerated  breast,  which  I  removed  after  death,  or  seventeen  years  and  a 
half  from  the  first  appearance  of  the  growth,  from  a  multiparous  widow  sixty- 
three  years  of  age.  The  skin  over  the  entire  thoracic  region  was  pervaded  by 
secondary  nodules;  the  opposite  mamma  and  axillary  glands  were  invaded  ;  the 
pectoral  muscles  of  the  corresponding  side  were,  for  the  most  part,  converted 
into  densely  hard  carcinomatous  material,  and  the  axillary  and  supraclavicular 
glands  were  indurated  and  much  enlarged.     Both  pleurae  and  both  lungs,  the 


132 


VARIETIES. 


or  sclerosed  bands  of  fibrous  tissue,  whicli  contain 
fatty   detritus,  or,   as   is   sbown  in   fig.    21,'  one  or 


Fio.  21. 


Atrophying  SciRRHrs. — Showing  long  spaces  occupied,  for  the  most  part,  by  a 
single  row  of  ceils,  and  contained  between  thick  bundles  of  fibrous  tissue. 

more  rows  of  uncliano;ed  cells.  Were  it  not  for  the 
fact  that  tbe  peripheral  zones  of  the  growth  dis- 
close the  usual  stmctui^e  of  scirrhus,  as  in  fig.  18, 
from  the  same  specimen,  atrophying  carcinoma  might 
readily  be  confounded  with  contracting  fibroma. 

2.  MuLTiCELLFLAE  Caecestoma  IS  syuouymous  with 
the  acinous  carcinoma  of  Billroth,  and  the  tuberous, 
medullary,  encephaloid,  soft,  or  acute  cancer  of  the 
clinician,  and  is  characterized  by  the  enormous  pro- 
duction of  the  epithelial  constituents,  and  the  rela- 
tively small  amount  of  the  supporting  connective 
tissue,  through  which  the  viddth  of  the  alveoli  is  far 
greater  than  that  of  the  trabeculse  of  fibrous  tissue 
which  form,  their  waEs,  as  is  seen  in  fig.  22." 

bronchial  and  mediastinal  glands,  the  opposite  half  of  the  diaphragm,,  and  one 
kidney  were  the  seat  of  metastatic  tumors. 

'  From  a  section  near  the  advancing  margin  of  a  tumor  of  fourteen  years' 
duration,  the  history  of  which  is  attached  to  fig.  18,  and  the  gross  appear- 
ances of  which  are  represented  in  fig.  29. 

*  From  a  section  of  a  tolerably  firm  and  elastic  tumor,  nearly  as  large  as  a 


CARCINOMA.  133 

Tlie  cells  of  tliis  variety  are  not  only  mucli  larger, 
and  more  liable  to  fatty  changes  than  those  of  any 


ExcEPHALoiD  Carcinoma. — Showing  the  large  size  of  the  alveoli,  the  walls  of 
which  are  constituted  by  thin  bands  of  young  connective  tissue.  The  nuclei 
of  the  cells  are  alone  represented. 

other  form  of  carcinoma,  but  they  are  frequently  the 
seat  of  endogenous  growth  or  vacuolation,  as  is  so 
strikingly  represented  in  fig.  23.' 

child's  head,  and  weighing  over  three  pounds,  removed  from  a  married  and  pro- 
lific woman  seventy-one  years  of  age.  It  had  begun  three  years  previously,  and 
was  attributed  to  a  severe  blow.  Above  and  to  the  inside  of  the  retracted  nip- 
ple there  was  a  tuber  of  the  volume  of  a  small  orange,  and  covered  by  thin, 
adherent,  and  discolored  skin.  Radiating  from  the  nipple  toward  the  axilla 
there  were  a  number  of  beaded  lymphatic  vessels,  and  the  axillary  glands 
formed  a  tumor  as  large  as  a  turkey's  egg.  During  the  last  four  months  of  its 
existence  it  had  increased  rapidly,  and  produced  great  discomfort  from  its 
weight.  The  greater  and  lesser  pectoral  muscles  were  extensively  infiltrated. 
On  section,  there  was  an  escape  of  thin,  sanguinolent  fluid,  and  the  cut  surfaces 
of  the  mass  were  pervaded  by  yellowish  areas  of  caseous  degeneration. 

'  From  a  section  of  a  soft  tumor  of  nine  months'  duration,  removed  by 
Professor  Agnew  from  a  multiparous  married  lady,  fifty-three  years  of  age.  The 
subcutaneous  veins  were  somewhat  enlarged  ;  but  the  skin,  nipple,  and  axillary 
glands  were  normal,  and  there  were  no  adhesions.  The  disease  recurred  in  the 
cicatrix  in  two  months,  increased  rapidly,  was  painful,  and  occasionally  bled  ; 
and  death  ensued  suddenly,  three  months  and  a  half  subsequently. 


134  VARIETIES. 

In  four  specimens  "wliicli  I  examined,  tlie  deli- 
cate trabeculse  of  the  stroma  were  infiltrated  by 
small  cells  in  three,  and  composed  of  a  spindle-celled 
tissue  in  the  other,  so  that  it  might  mth  propriety 

Fig.  23 


Encephaloid  Carcinoma. — The  alveoli  are  filled  with  large  cells,  almost  all  of 
which  arc  vacuolated.  The  largest  contain  a  nucleated  cell,  while  many, 
from  the  sitnation  of  the  nucleus  at  their  periphery,  present  the  character- 
istic signet-ring  appearance.    A  few  are  merely  hollow  vesicles. 

be  called  a  sarcomatous  carcinoma,  of  which  an  illus- 
tration is  to  be  found  in  Mr.  Amott's  monograph  on 
The  Histology  and  Diagnosis  of  Cancer.  In  other 
specimens  the  walls  of  the  alveoli  are  constituted 
mainly  by  embiyonic  bloodvessels  suri'ounded  by  a 
thin  layer  of  soft  connective  tissue,  giving  rise  to 
telangiectatic  carcinoma,  or  fungus  hematodes,  as  it 
is  more  commonly  teimed,  from  its  macroscopic  fea- 
tures. It  should  be  observ^ed  that  medullaiy  carci- 
noma is  not  always  a  soft  tumor.  The  specimen  from 
which  fig.  22  was  derived  was  tolerably  finn  and  elas- 
tic, and  the  cells  had  not  undergone  advanced  fatty 
changes,  so  that  the  masses  of  cells  distended  the 
alveoli  to  the  uttennost.  Under  opposite  circum 
stances,  or  when  the  cells  have  de2:enerated,  and  the 


CARCINOMA. 


135 


tension  of  tlie  alveoli  is  lessened  or  lost,  the  gro^Yth 
is  soft  and  even  pseudofluctuating. 

3.  Colloid  Cakclnoma. — Colloid,  or  gelatinous, 
carcinoma  differs  from  tlie  preceding  varieties  only 
in  the  fact  that  the  protoplasm  of  its  cells  has  under- 
gone colloid  degeneration.'  It  is  sometimes  called 
mucous,  or  alveolar,  cancer;  but  as  the  metamorpho- 


FiG   24. 


Colloid  Carcinoma. — Showing  the  large  alveoli  distended  by  the  colloid  mate- 
rial, in  which  are  contained  a  few  cells  and  concentric  lamintE  of  cellular 
detritus. 


sis  is  not  of  a  mucoid  nature,  and  as  all  carcinomata 
are  alveolar,  these  tenns  are  misnomers. 

A  section  of  such  a  tumor  discloses  that,  in  its 

*  Although  Billroth,  Wagner,  Klebs,  Waldeyer,  and  other  pathologists  teach 
that  colloid  cancer  is  merely  an  ordinary  cancer  in  the  highest  stage  of  colloid 
metamorphosis  of  its  cells,  Virchow  and  Lebert  hold  that  it  depends  upon  the  col- 
loid character  of  its  stroma ;  Foerster  and  F.  E.  Schulze  upon  colloid  degenera- 
tion of  both  the  cells  and  stroma ;  and  Doutrelepont,  with  whom  Rindfleisch 
appears  to  agree,  upon  colloid  transformation  of  the  amorphous  formative  or 
germinal  material,  out  of  which,  under  ordinary  circumstances,  the  young  cells 
of  carcinoma  are  derived. 


136  ■  VARIETIES. 

early  stage,  the  lieaps  of  cells  are  merely  separated 
from  the  walls  of  the  alveoli  by  a  structureless  col- 
loid substance.  As  the  transformation  advances,  the 
cells,  as  in  fig.  24,  from  Eindiieisch,  are  massed  toward 
the  centre  of  the  greatly  enlarged  alveoli,  and  sur- 
rounded by  the  colloid  material,  which  is  marked  by 
concentric  circles  or  layers  of  dotted  lines,  the  dots 
representing  the  nuclei  and  granular  remains  of  the 
cells  that  have  been  successively  invaded  by  the 
chansfe.  With  the  still  further  advance  of  the  meta- 
morphosis,  the  cells  disappear  entirely,  and  nothing 
remains  save  the  lamination  or  concentric  stratifica- 
tion of  the  homoo'eneous  substance.  In  none  of  the 
accounts  of  colloid  carcinoma  of  the  breast  that  I 
have  examined  have  the  cells  assumed  the  bandbox 
or  oyster-shell  appearance  that  is  met  with  in  similar 
tumors  of  other  organs,  so  that  the  large,  refractory, 
vesicular  cells  and  the  lamination  are  the  most  char- 
acteristic features  of  the  neojjlasm.  In  some  cases, 
indeed,  the  cells  were  only  the  seat  of  fatty  degenera- 
tion. 

4.  Melanotic,  oe  Pigmented,  Caecinoima  is  char- 
acterized by  the  infiltration  of  the  cells  with  granules 
of  melanin  or  altered  hematoidin. 

5.  Cystic  Caecinoma. — It  sometimes  happens  that 
the  obstructed  and  dilated  terminal  acini  and  ducts 
of  mammse  which  are  the  seat  of  cancer  are  converted 
into  cysts  through  mucoid  or  fatty  transformation  of 
their  epithelium.  In  addition  to  these  simple  reten- 
tion or  involution  cysts,  that  are  combined  with,  al- 
though they  precede  the  development  of,  carcinoma, 


CARCmOMA.  137 

cysts  are  sometimes  met  with,  as  in  fig.  25/  wliicli 
are  more  or  less  completely  filled  mtli  vascular,  epi- 
thelial-clad vegetations,  or  papillae,  which  are  merely 
protrusions  of  the  periacinous  connective  tissue  into 
their  interior,  and  are  themselves  devoid  of  carcino- 

FiG    25 


Cystic  Excephaloid  Carcinoma. — Showing,  in  addition  to   simple  cysts,  two 
cavities  occupied  by  vegetations. 

matous  structure.  Comil  and  Ranvier^  describe  this 
proliferating  foiTQ  as  villous  carcinoma;  while  Neu- 
mann '  terms  the  case  which  he  records  encysted 
medullary  carcinoma.  It  is  not,  however,  peculiar  to 
soft  carcinoma,  as  a  specimen  of  scirrhus  in  the  col- 
lection of  Professor  Gross  shows  a  similar  combina- 
tion ;  and  Mr.  Wood  *  reports  an  example  of  hard  car- 
cinoma of  the  male  mamma  in  which  the  papillae  were 
so  vascular  as  to  convert  the  cavities  containing  them 
into  blood  cysts. 

In  addition  to  the  preceding  varieties,  we  may 
have  a  myxomatous  cancer  through  mucous  transfor- 
mation of  the  stroma,  or  a  calcifying  cancer  through 

'  From  a  medullary  carcinoma,  devoid  of  history,  from  the  cabinet  of  Pro- 
fessor Gross. 

»  Op.  cit.,  p.  1167. 

*  Virchoto's  Archiv,  Bd.  xxiv,  p.  319. 

*  Trans.  Path.  Soc.  London,  vol.  xxv,  p.  223. 


138  VAEIETIES. 

the  deposition  of  the  salts  of  lime  in  the  alveoli  and 
between  the  trabeculse  of  the  framework,  as  in  the 
examples  recorded  by  Ackermann '  and  Creighton ; ' 
or  the  fat  cells  of  the  stroma  may  preponderate  to 
such  an  extent  as  to  constitute  a  lipomatous  carcino- 
ma. These  changes  are,  however,  met  with  to  so 
limited  an  extent  that  they  can  scarcely  be  said  to 
constitute  varieties,  although,  if  it  be  deemed  desir- 
able to  notice  them,  they  may  be  retained  as  prefixes 
to  indicate  suboidinate  degenerations  and  transfor- 
mations. 

The  gross  characters  of  the  varieties  of  carcinoma 
correspond  so  closely  to  their  minute  features  that  the 
true  nature  of  a  specimen  may  be  pretty  accurately 
determined  by  its  macroscopic  appearances.  Ordinary 
scirrhus  has  an  irregular,  rounded,  nodular  outline, 
and  is  frequently  flattened,  or  slightly  cupped,  on  its 
pectoral  surface,  so  that  it  assumes  a  discoid  shape.  Its 
size  is  moderate,  being  usually  not  larger  than  a  small 
lemon.  Its  consistence  is  densely  hard  and  unyield- 
ing, and  it  is  heavier  than  any  other  mammary  neo- 
plasm of  equal  volume.  On  section,  it  is  crisp  and 
tough,  and  the  cut  surfaces  contract  and  become  con- 
cave, and  exude,  on  pressure  or  scraping,  a  milky  or 
turbid  granular  fluid  or  juice.  The  homogeneous,  re- 
fracting, grayish- white  surface  is  made  up  of  interlac- 
ing bands,  between  which  are  intercalated  yellowish- 
gray  or  yellow  granular  si:)ots  or  dots,  and  lines  or 
stripes,  which  are  indicative  of  fatty  and  caseous  degen- 
eration of  the  cells.  At  the  periphery  the  section  is 
also  marked  by  pellets  of  normal  fat,  from  their  inclu- 
sion in  the  advancing  infiltration. 

'  Virchovi's  Archiv,  Bd.  xlv,  p.  60.  ,/"  Op  a7.,p.  169. 


CARCINOMA.  139 

Simple  carcinoma  lias  a  bossed  outline,  and  attains 
a  much  larger  bulk  than  the  preceding  variety,  the 
volume  of  a  large  orange  being  not  infrequent ;  or  it 
may  even  measure  between  five  and  six  inches  in 
diameter,  as  happened  in  one  of  my  cases.  Its  con- 
sistence is  firm,  rather  than  hard ;  its  section  is  mod- 
erately tough,  and  the  cut  surfaces  do  not  become 
concave.  The  juice  is  more  abundant  and  more 
grumous;  and  areas  of  caseation,  softening,  and  in- 
creased vascularity  are  not  uncommon. 

Medullary  carcinoma  exhibits  the  same  general 
characters  as  the  simple  variety,  although  it  is  usu- 
ally lobulated,  and  attains  still  larger  dimensions,  the 
volume  of  a  child's  head  being  quite  frequent.  Its. 
consistence  is  generally  soft  and  elastic,  and  even 
pseudofluctuating.  The  firm  variety  has  a  homoge- 
neous white  surface  on  section,  while  the  soft  form  is 
made  up  of  a  grayish-white  basis,  mottled  with  pink, 
red,  or  brown  areas,  indicative  of  increased  vascular- 
ity and  slight  effusions  of  blood.  When  the  tissue 
resembles  a  recent  coagulum,  or  contains  spaces  filled 
with  blood,  the  tumor  is  termed  hematoid  cancer, 
which  is  synonymous  with  fungus  hematodes. 

Atrophying  scirrhus  is  the  most  dense,  rigid,  and 
inflexibly  hard,  and  at  the  same  time  the  smallest,  of 
all  the  varieties.  It  creaks  under  the  knife ;  and  its 
cut  surfaces  are  deeply  concave,  of  a  tendinous,  glis- 
tening, bluish-gray  lustre,  and  dotted  here  and  there 
with  pale  yellow  granular  spots."  The  juice,  if  any 
at  all  can  be  expressed,  is  of  a  thin  and  citron-colored 
serous  nature. 

Colloid  carcinoma  is,  as  a  rule,  as  hard  as  ordi- 
naiy  scirrhus.     Only  one  specimen  in  every  twelve  is 


140  VARIETIES. 

soft;  and  it  seldom  attains  larger  dimensions  tlian 
tliat  variety,  a  volume  of  tlie  fist  being  exceptional, 
and  tlien  only  after  a  very  clironic  course.  The  cut 
surfaces  are  cliaracterized  by  an  exquisite  alveolar 
structure,  filled  with  a  translucent,  or  a  cloudy -yel- 
lowish,  yellowisli-gray,  or  grayish-white,  or  possibly 
blood-stained,  gelatinous  substance. 

Melanotic  cancer  is  nothing  more  than  ordinary 
scirrhus  in  a  state  of  pigmentation. 

In  cystic  carcinoma  the  cut  surfaces  are  pervaded 
by  cavities,  which  vary  in  size  from  a  millet-seed  to  a 
walnut,  and  contain  either  fluid  or  solid  contents,  the 
latter  being  in  the  form  of  dendritic  vegetations, 
that  impart  to  the  section  the  appearance  of  a  vege- 
tating or  proliferating  fibroma  or  sarcoma.  The  basis 
of  such  tumors  is  usually  composed  of  medullary 
tissue,  although  ordinary  scin^hous  carcinoma  is  not 
free  from  these  chansres. 

As  a  class,  the  carcinomatous  tumors  may  be  dis- 
tinguished from  the  non-carcinomatous  by  their  in- 
separable connection  with  the  breast,  which  they 
infiltrate,  so  that  they  are  not  provided  with  a  limit- 
ing capsule ;  by  their  containing  areas  of  fat ;  and 
by  the  absence  of  large  intracanalicular  vegetations, 
which  are  so  common  in  the  cystic  variety  of  the  lat- 
ter growths.  Ordinary  scirrhus  is  also  characterized 
by  the  concave  appearance  of  its  cut  surfaces. 

Of  the  relative  frequency  of  the  varieties  of  carci- 
noma, it  may  be  said  that  out  of  every  100  cases'  we 
may  expect  to  find  77  of  ordinary  scirrhus,  11  of  sim- 

'  Based  upon  56  minute  examinations  made  by  myself,  and  64  out  of  192 
cases  tabulated  by  Dr.  A.  Henry,  in  his  Slatistiche  MUtheilungen  uher  den  Brust- 
krebs,  Breslau,  1879. 


CARCINOMA.  141 

pie  carcinoma,  7  of  atropliying  scirrlius,  and  5  of  en- 
ceplialoid  carcinoma.  Combination  with  cysts  is  so 
rare  that  I  have  met  with  them  only  once  out  of  fifty- 
six  specimens.  Colloid  carcinoma  is  so  excessively 
infi-equent  that  I  have  never  seen  it ;  nor  is  it  referred 
to  by  Bilh^oth '  in  a  record  of  245  cases ;  nor  by  Hen- 
ry and  by  Oldekoi^ "  in  their  tables,  respectively,  of 
192  and  250  examples.  Melanotic  carcinoma  of  the 
female  mamma  is,  as  far  as  I  am  aware,  unknown, 
although  Marcano  ^  and  Chenet  *  each  report  a  case 
as  occuiTing  in  the  male  mamma ;  and  Billroth  ^  de- 
scribes a  carcinoma  of  the  female  breast  with  a  pig- 
mented alveolar  stroma. 

In  addition  to  colloid  transformation,  calcareous 
infiltration,  and  pigmentation,  carcinoma  is  excessively 
liable  to  fatty  and  granular  degeneration  of  its  cells, 
and  less  frequently  to  caseation  through  atrophy  and 
desiccation  of  the  fatty  cells.  These  changes,  which 
are  indicated  macroscopically  by  yellow  or  yellowish- 
white  spots  or  streaks,  constitute  the  regressive  carci- 
noma of  Heinrich  Meckel,  or  the  reticular  carcinoma 
of  Johannes  Mliller;  and  they  always  precede  the 
cicatricial  formation  met  with  in  atrophying  scirrhus. 
Cystoid  spaces  or  cavities  not  infrequently  result  from 
the  disintegration  of  the  cells,  and  the  accumulation 
of  the  turbid  fatty  detritus  in  the  softened  tumors, 
over  which,  if  superficially  seated,  the  discolored  skin 

'  CIdr.  lUinik,  Wien,  1871-"76,  p.  266. 

"  Slatistiche  ZusammensteVunrf  der  in  der  Klinik  des  Herrn  Prof.  Dr.  Esmarch 
zu  Kid  in  den  Jahren,  von  1850-1878,  beobachten  230  Fdlle  von  Mamma-Carci- 
nom.     Lanffeiibeck^s  Archiv,  Bd.  xxix,  pp.  536  and  693. 

^  Bull,  de  la  Soc.  Anat.,  t.  xlix,  p.  921. 

*  Virchoiv-HirsdCs  Jahreshericht,  Bd.  ii,  1876,  p.  422. 

6  Chir.  lUinik,  Wien,  1869-"70,  p.  177. 


142  ETIOLOGY. 

finally  gives  way.  In  the  event  of  tlie  bloodvessels 
of  tlie  stroma  being  attacked  by  fatty  degeneration, 
these  softening  cysts  also  contain  extravasated  blood. 

AVlien  cancer  takes  on  rapid  growth,  and  is  attended 
by  an  extensive  small-celled  infiltration  of  its  frame- 
work, it  is  prone  to  inflame,  as  is  indicated  clinically 
by  increase  of  suffering,  elevated  temperature,  and 
discoloration  of  the  skin.  Under  these  circumstances, 
and  particularly  when  the  tumor  develops  during 
pregnancy  or  lactation,  an  abscess  may  form  at  the 
expense  of  the  infiltrated  connective  tissue,  the  epi- 
thelial cells  themselves  not  participating  in  the  mor- 
bid process.  Even  when  the  mamma  is  not  function- 
ally active,  suppuration  may  ensue,  as  in  the  case  of 
a  married  sterile  woman,  thirty-nine  years  of  age, 
whose  breast  I  extirpated  last  July.  The  tumor,  which 
had  acquired  the  volume  of  an  e^g  in  less  than  two 
months,  contained  an  abscess  as  large  as  a  filbert, 
filled  with  greenish  pus. 

Carcinoma '  never  develops  before  puberty ;  and 
I  have  never  seen  it  before  the  twenty-eighth  year,  al- 
though Henry  records  a  case  at  twenty-one,  which  is, 
if  I  do  not  mistake,  the  earliest  that  has  been  obseiVed. 
It  is  very  rare  before  thirty,  after  which  age  it  grad- 
ually increases  to  between  forty-five  and  fifty,  when 
it  reaches  its  maximum  of  frequency,  forty- eight  years 
being  the  average,  and  then  decreases ;  it  is  very  un- 
common after  seventy.  Of  642  cases,  in  which  the 
age  is  noted, 

'  The  general  patholopiy  of  cancer  is  based  mainly  upon  a  study  of  712 
cases,  of  which  250  arc  recorded  by  Oldekop  from  Esmarch's  clinic,  192  by 
Henry  from  the  Breslau  clinic,  170  by  Von  Winiwarter  from  Billroth's  clinic, 
and  analyzed  in  his  Beitrdge  ziir  Statislik  dor  Carcinome,  Stuttgart,  1878,  and 
100  by  myself  in  the  Boston  Medical  and  Surgical  Journal,  March  25,  1880. 


CARCINOMA.  143 

18  first  appeared  between  20  aud  30  years  of  age. 


128 
245 
165 

78 


30  "  40 

40  "  50 

50  "  60 

60  "  70 

70  "  80 


Of  tlie  entire  number  not  one  was  observed  during 
tlie  developmental  state  of  tlie  mamma ;  146,  or  22*74 
per  cent.,  appeared  during  the  period  of  its  greatest 
activity,  or  up  to  the  age  of  forty;  and  496,  or  77*26 
per  cent.,  began  after  that  age,  or  during  its  func- 
tional decline. 

Of  187  cases,  analyzed  by  Winiwarter  and  myself, 
in  which  the  catamenise  are  mentioned,  115,  or  61*5 
per  cent.,  were  menstiniating  at  the  date  of  the  de- 
velopment of  the  disease ;  and  only  6*41  per  cent, 
of  these  were  irregular  in  the  performance  of  that 
function. 

Of  688  women  in  whom  the  social  condition  is 
noted,  607,  or  88*22  per  cent.,  were  or  had  been  mar- 
ried, and  81,  or  1 1*77  per  cent.,  were  single.  Of  435 
in  whom  it  is  mentioned,  365,  or  83*91  per  cent.,  had 
borne  children,  and  of  these  nearly  nine-tenths  had 
more  than  one  child ;  while  70,  or  16*09  per  cent., 
were  barren.  With  regard  to  nursing,  I  find  that,  of 
259  patients  in  whom  it  is  refeiTed  to,  191,  or  73*74 
per  cent.,  had  suckled  their  infants,  while  68,  or 
26*25  per  cent.,  had  not.  In  13  of  262  fertile  women, 
or  nearly  5  per  cent.,  the  disease  is  stated  to  have 
developed  during  pregnancy  or  lactation. 

The  influence  of  hereditary  predisposition  and  of 
the  general  bad  health  of  the  subjects  upon  the  de. 
velopment  of  carcinoma  is  not  so  marked  as  some 
teachers  would  lead  us  to  believe.      Thus,  of  389 


144  ETIOLOGY. 

women,  in  wliom  the  former  point  is  noted,  40,  or  1 
in  every  9-72,  stated  that  cancer  had  occurred  in  their 
ancestors;  while  of  189  in  whom  the  general  condi- 
tion is  mentioned,  97,  or  51  per  cent.,  were  in  robust 
health;  34,  or  18  per  cent,  were  in  good  health;  37, 
or  19  per  cent.,  were  pale  and  thin ;  and  21,  or  12 
per  cent.,  were  decidedly  broken  down  from  the  effects 
of  the  disease.  Hence,  even  when  the  patients  first 
come  under  observation,  less  than  one-thii'd  appear  to 
be  injuriously  influenced  by  the  progress  of  the  affec- 
tion ;  and  it  may  safely  be  asserted  that  the  nutrition 
of  scarcely  one  in  twenty  suffers  previous  to  sixteen 
months  after  the  detection  of  the  growth. 

In  addition  to  the  foregoing  antecedents,  there 'are 
other  conditions  which  are  assumed  to  excite  the  de- 
velopment of  cancer.  Thus,  in  11*7  per  cent.,  or  23 
out  of  270  cases,  analyzed  by  Winiwarter  and  myseK, 
the  disease  was  ascribable  to  trauma,  as  blows  and 
contusions ;  in  5,  or  1*35  per  cent.,  of  the  370  cases 
fi'om  Oldekop's  and  my  own  tables,  it  was  preceded 
by  eczema  or  psoriasis  of  the  nipple ;  *  and  it  started 
from  lumps  or  chronic  indurations  left  by  puerperal 
mastitis  in  30,  or  8*21  per  cent,  of  the  365  women 
who  had  borae  children. 

Carcinoma  usually  commences  as  a  small,  pain- 
less, circumscribed,  densely  hard,  uneven,  or  nodulated 
tuber,  which  is  movable  under  the  skin,  but  fixed  in 
or  to  the  breast  itself.  In  1  case  out  of  every  48,  or 
in  2*08  per  cent.,  several  distinct  nodules  are  met 
with,  which  evince  a  marked  tendency  to  coalesce 
as  the  disease  progresses.     It  now  and  then  occurs 

'  Mr.  Henry  Morris  records,  in  the  London  Lo.ncet,  vol.  ii,  1879,  p.  873,  ante- 
cedent eczema  in  2  out  of  305  cases,  which  reduces  the  percentage  to  r03. 


CARCINOMA.  145 

as  an  infiltration  of  tlie  entire  gland.  It  is  more  fre- 
quent, by  5-45  per  cent.,  in  the  right  than  in  the  left 
breast.  While  Olclekop  and  Winiwarter  agree  that 
the  upper  portion  of  the  outer  hemisphere  of  the 
mamma  is  its  most  common  seat,  my  own  100  cases 
show  that  56  occupied  the  vicinity  of  the  nipple,  7 
having  been  discovered  immediately  behind  that  body, 
19  at  its  outer  side,  12  at  its  inner  side,  6  below,  and 
12  above — facts  which  will  serve  to  explain,  as  I  shall 
indicate  presently,  the  frequency  with  which  I  have 
met  with  retraction  of  the  mammilla.  Of  the  remain- 
ing 44  cases,  33  were  located  toward  the  outer  cir- 
cumference, and  11  toward  the  inner  periphery,  and 
of  these  only  18  occupied  the  upper  hemisphere.  On 
the  whole,  the  seats  of  election  of  cancer  are  the  upper 
and  outer  quadrant,  and  the  immediate  neighborhood 
of  the  nipple. 

The  increase  of  carcinoma,  when  compared  with 
the  other  mammary  neoplasms,  is  slow,  so  that  it 
rarely  attains  any  considerable  bulk.  In  ordinary 
scirrhous  and  colloid  cancer  the  tumor  is  usually 
smaller  than  the  gland  or  portion  of  the  gland  that  it 
has  replaced;  in  simple  scirrhus  the  volume  of  a 
small  fist  is  not  uncommon,  and  it  may  even  measure 
five  inches  and  a  half  in  diameter,  as  happened  in  one 
of  my  cases  which  had  lasted  three  years  before  it 
was  extirpated ;  in  withering  scirrhus,  the  tumor  is 
rarely  as  large  as  a  walnut,  while  in  medullary  carci- 
noma the  size  of  a  child's  head  is  not  uncommon. 
Hence  the  volume  depends  upon  the  relative  propor- 
tion of  the  component  constituents,  being  large  when 
the  cells  predominate,  and  small  when  the  fibrous 
stroma  is  in  excess. 
10 


146  SYMPTOMS. 

The  rate  of  growtli  is  not,  contrary  to  tlie  generally 
received  opinion,  influenced  by  tlie  early  age  of  tlie 
patient,  since  I  have  failed  to  discover  that  the  in- 
crease is  more  rapid  before  the  age  of  forty  than  when 
the  tumor  develops  later  in  life.  "When,  however, 
carcinoma  appears  during  pregnancy  or  during  lacta- 
tion, its  growth  is  wonderfully  rapid,  and  its  course  is 
excessively  malignant,  of  which  fact  several  striking 
instances  are  recorded  by  Klotz '  and  Paget.''  In  a 
case  reported  by  Billroth,'  the  disease  developed  in 
both  breasts  five  weeks  before  the  woman's  eighth 
confinement ;  and  on  death,  one  week  after  an  easy 
and  natural  delivery,  or  six  weeks  after  the  first  ob- 
servation of  the  disease,  the  mammae  were  larger 
than  a  child's  head,  and  secondary  deposits  were 
found  in  the  thyroid  gland,  pericardium,  liver,  omen- 
tum, and  kidneys. 

During  its  further  increase — and  it  grows  by  pro- 
gressively invading  or  infiltrating  the  tissues  at  its 
periphery — or  when  it  has  attained  only  a  moderate 
volume,  carcinoma  evinces  signs  which  are  of  great 
diagnostic  value  even  before  the  contiguous  struc- 
tures are  visibly  contaminated,  and  which  are  refer- 
able to  its  tendency  to  contract  or  draw  the  compo- 
nent tissues  of  the  breast  itself  and  the  adjacent 
structures  into  its  midst — a  tendency  due  to  cicatri- 
cial or  atrophic  changes  going  on  in  its  older  or  more 
central  portions. 

Among  the  earliest  of  these  phenomena,  particu- 
larly when  the  tumor  is  superficial,  is  a  dimpling  or 

1  Uther  Mastitis  Carcinomotosa  Gravidarum  et  Ladantium.     Inaug.  Diss., 
Halle,  1869. 

*  Op.  cit.,  p.  639. 

'  Chir.  Klinik,  Wien,  18'71-'76,  p.  258.  ^ 


CARCINOMA.  147 

pitting  of  tlie  skin.  This  pitting  is  entirely  indepen- 
dent of  carcinomatous  adhesion  between  the  skin  and 
the  growth,  and  arises  from  shortening  of  the  fibrous 
bands  or  processes  of  the  superfcial  mammaiy  fascia 
which  pass  from  the  posterior  surface  of  the  skin 
into  the  interior  of  the  breast,  and  which  Sir  Astley 
Cooper  called  the  suspensory  ligaments.  This  sign, 
along  with  the  age  of  the  patient  and  the  consistence 
of  the  growth,  enabled  me  to  diagnose  the  true  na- 
ture of  a  tumor  of  the  size  of  a  small  filbert,  and  of 
five  months'  duration,  situated  at  the  clavicular  bor- 
der of  the  gland,  before  its  removal. 

In  5*22  per  cent,  of  the  non-carcinomatous  neo- 
plasms of  the  breast  the  nipple  is  buried,  displaced,  or 
sunken,  simply  for  the  reason  that  the  tumor  grows 
beyond  its  level,  so  that  by  pushing  back  the  former 
the  nipple  again  partly  protrudes.  In  carcinoma,  on 
the  other  hand,  the  mammilla  is  permanently  retract- 
ed and  fixed,  as  is  shown  in  fig.  29,  because  the  con- 
tracting growth  draws  it  toward  itself  by  shortening 
the  milk  ducts  which  teiTiiinate  at  its  extremity;  and 
this  process  is  the  more  apparent  when  the  neoplasm 
develops  in  the  immediate  vicinity  of  the  lacteal  si- 
nuses, or  when  the  nipple  itself  is  infiltrated  and 
becomes  the  seat  of  cicatricial  contraction.  In  my 
own  100  cases — and  Winiwarter,  Henry,  and  Olde- 
kop  do  not  refer  to  this  point — a  retracted  nipple 
was  observed  in  not  less  than  52 ;  and  as  it  was 
sunken  in  only  1  out  of  every  19^  examples  of  the 
non-carcinomatous  neoplasms,  I  regard  it  as  a  sign 
the  value  of  which  cannot  be  overestimated.  In  one 
of  my  patients  it  was  the  first  sign,  along  with  a  straw- 
colored  discharge,  that  directed  attention  to  the  disease. 


148  LOCAL  EXTENSION. 

To  the  same  cause,  or  intraction  of,  combined 
with  pressure  upon,  the  nervous  filaments  which  sup- 
ply the  breast,  may  be  ascribed  the  pain  of  which 
patients  so  commonly  and  so  early  complain.  Usu- 
ally of  an  intermittent,  darting,  pricking,  or  neuralgic 
character  at  the  outset,  the  suffering  becomes  more 
constant  and  aggravated  with  the  progress  of  the  dis- 
ease, and  particularly  when  the  skin  is  extensively 
invaded  and  ulcerated,  and  the  lymphatic  glands  in- 
filtrated, until,  finally,  it  is  frequently  atrocious ;  ex- 
tending in  various  directions,  as,  for  example,  to  the 
shoulder,  neck,  back,  and  arms,  interfering  with  sleep 
and  nutrition,  and  hastening  the  fatal  issue.  In  4 
per  cent,  of  all  cases  there  is  absolutely  no  suffering 
whatever ;  in  8  per  cent,  there  is  merely  a  sensation 
of  discomfort  or  weight ;  while  in  88  per  cent,  there 
is  real  pain,  which  varies,  however,  greatly  in  inten- 
sity and  character. 

With  the  further  advance  of  the  disease,  but  not, 
on  an  average,  before  the  expiration  of  thirteen 
months  after  its  first  obsen^ation,  marked  chansres 
ensue.  These  indicate,  first,  local  infection,  or  region- 
al dissemination,  through  the  extension  or  growth 
of  young  epithelial  cells,  along  the  course  of  the 
lymph  and  bloodvessels,*  into  the  adjacent  tissues; 
and,  secondly,  the  transfer  of  the  cells  by  the  lym- 
phatic vessels  to  the  associated  lymphatic  glands. 
These  changes,  when  regarded  in  their  chronological 
order,  are  invasion  of  the  skin,  the  glands,  the  muscles 
of  the  chest,  the  ribs,  the  pleura,  and  the  opposite 
breast. 

Infection   of  the  contiguous  tissues  shows  itself 

^  The  transfer  of  infectious  cells  along  the  bloodvessels  is  shown  in  fig.  18. 


CARCINOMA. 


149 


either  in  tlie  form  of  adhesion  or  fixation  of  the  tumor 
to  the  skin  and  walls  of  the  chest,  or  as  distinct  nod- 
ules or  tubers  which  are  visible  to  the  naked  eye  when 
superficial,  or  are  detected  during  operative  procedures. 
Of  631  cases,  in  which  the  point  is  noted,  inva- 


Fio   26. 


Disseminated  Simple  Carcinoma. 


sion  of  the  skin,  as  evinced  by  its  adhesion  or  discol- 
oration, was  met  vdth  in  218,  or  34"54  per  cent.;  by 
the  formation  of  tubers  in  67,  or  10*61  per  cent. ;  and 
by  ulceration  in  150,  or  23'77  per  cent.,  so  that  it  is 


150  LOCAL  EXTENSION. 

involved  in  68*92  per  cent,  of  all  instances.  In  tlie 
majority  of  cases,  the  skin  is  adherent,  thinned,  and 
of  a  purplish,  bluish-red,  or  dusky -red  tint,  with  en- 
largement of  its  small  vessels,  and  possibly  superfi- 
cial and  limited  desquamation,  conditions  which  pre- 
cede ulceration.  In  some  examples  it  is  rigid  and 
brawny,  like  the  skin  of  a  lemon  or  the  rind  of  bacon, 
and,  now  and  then,  pervaded  by  vaiicose  lymphatics 
and  oedematous ;  or  it  may  be  drawn  in  so  as  to  resem- 
ble a  cicatrix.  When  nodules  form,  they  may  present 
the  appearance  of  flat,  iri'egular  plates ;  but  they  are 
usually  shot-like  or  pea-like  or  biconvex,  and  fre- 
quently attain  the  size  of  a  hazel-nut  or  a  small  hick- 
ory-nut, and  are  covered  by  discolored  skin.  Occa- 
sionally, and  particularly  when  the  subcutaneous  con- 
nective tissue  is  simultaneously  involved,  they  form 
large  masses,  as  in  fig.  26  *  from  one  of  my  cases, 

'  Eliza  C,  aged  fifty-five  years,  the  mother  of  two  children,  ceased  to  men- 
struate fourteen  years  ago,  and  was  not  aware  of  a  family  history  of  cancer. 
About  two  years  ago,  while  washing  the  right  breast,  she  accidentally  noticed  a 
firmly  fixed,  painless  growth,  as  large  as  an  English  walnut,  two  inches  above 
and  to  the  right  of  the  nipple.  She  remained  in  this  condition  for  twelve 
months,  when  the  skin  around  the  base  of  the  mammilla  became  ulcerated,  and 
discharged  a  thin  and  fetid  fluid.  Excessive  pain  of  a  darting  and  cutting  na- 
ture manifested  itself  at  the  same  time,  and  had  continued  ever  since,  with 
remissions  in  severity.  She  stated  that  the  original  tumor  gradually  disap- 
peared, and  that  small  lumps,  "  like  peas,"  made  their  appearance  in  the  skin 
to  the  inner  side  of  the  affected  breast,  and  extended  to  the  left  breast  nine 
months  ago.  The  entire  anterior  surface  of  the  thorax  looked  as  if  it  had  been 
converted  into  an  irregular  fungous  mass,  covered  here  and  there  with  drops 
of  blood  and  yellowish  pus.  On  closer  inspection,  however,  the  red  and  promi- 
nent nodules  and  bosses  were  seen  to  be  free  from  the  ordinary  appearances  of 
fungus,  their  surface  being,  for  the  most  part,  merely  excoriated  or  fissured, 
while  some  were  covered  by  crusts.  To  the  touch  they  were  firm,  and  somewhat 
elastic  and  tender.  Varying  in  size  from  a  small  shot  to  an  orange,  they  were 
multiform,  convex  on  both  surfaces,  and  inseparably  connected  with  the  chest. 
The  discharge  was  profuse,  and  had  a  sickening  odor.  Some  of  the  nodules 
showed  distinct  evidence  of  cicatrization  of  the  superficial  ulcers  in  the  form  of 
a  thin  epithelial  covering,  while  one  was  sloughing  off.    The  original  breast  and 


CARCINOMA.  151 

wliicli  extend  beyond  tlie  middle  line  of  tlie  chest, 
involve  the  opposite  breast,  ulcerate,  produce  great 
suffering,  and  finally  convert  the  front  and  sides  of 
the  thorax  into  a  mass  of  offensive  disease.  Under 
these  circumstances,  the  tubers  need  only  undergo 
atrophic  changes  to  constitute  the  affection  known  as 
cancer  en  cuirasse,  which  is  met  with  once  in  every 
fifty-one  cases.  When  withering  does  not  ensue,  the 
affection  is  termed  lenticular  cancer  by  Schuh,  and 
pustular  or  disseminated  scirrhus  by  Velpeau,  and 
the  disease  may  even  extend  to  the  neck,  shoulder, 
arm,  abdomen,  and  back.  In  other  cases,  by  the 
union  of  the  nodules  with  the  main  tumor,  and  by 
their  progressive  growth,  the  breast  is  convei'ted  into 
a  large  bossed  mass. 

Invasion  of  the  skin  is  the  earliest  perceptible  sign 
of  local  malignity,  but  it  may  be  delayed  for  seven  or 
eight  years.  I  have  met  with  it  as  early  as  the  sec- 
ond month ;  but  the  average  date  of  its  appearance  is 
14'1  months,  which  is  the  mean  of  13'9,  14*4,  and 
14-2  months  recorded,  respectively,  by  Winiwarter, 
Oldekop,  and  myself. 

Althouo;h  I  have  included  ulceration  amons:  the 
phenomena  of  infection  of  the  integument,  many 
ulcers  result  from  fatty  and  disintegrating  changes 
which  take  place  in  the  substance  of  the  tumor  itseK. 
Hence   the   process   may  be   superficially  or  deeply 

tumor  were  converted  into  a  large,  red,  thin,  adherent  cicatrix.  Of  the  left 
breast  nothing  remained  except  its  lower  half  with  the  deformed  nipple.  Three 
small  nodules  of  carcinoma  were  seated  in  the  skin  over  the  summit  of  the  left 
shoulder,  and  were  quite  independent  of  the  main  mass.  The  supraclavicular 
glands  of  the  right  side  were  contaminated,  and  a  cluster  of  hard  glands,  as 
large  as  an  egg,  occupied  each  axilla.  The  woman's  general  condition  was  ex- 
cellent. * 


152 


ULCERATION. 


seated.  In  tlie  former  event,  as  is  seen  in  fig.  26, 
tlie  thinned  and  discolored  skin  is  at  first  cracked, 
fissured,  excoriated,  or  eroded,  and  covered  by  thin 
crusts.  Ere  long  a  sore  forms,  wkicli  has  a  pale 
granulating  base,  and  discharges  a  thin,  offensive 
fluid.  Now  and  then  it  heals  over,  the  cicatrix 
being  thin,  tense,  red,  and  traversed  by  small  vessels  ; 


Local  Dissemination  and  Ulceration  of  Scirrhous  Carcinoma. 


or  healing  occurs  in  the  first  breach  of  continuity, 
while  the  ulceration  continues  to  spread.  In  the 
second  form  of  sore,  or  that  which  ensues  from  the 
breaking  down  of  the  tumor,  there  is,  as  is  delineated 


CARCINOMA.  153 

in  fig.  27/  a  deep,  excavated,  or  crater-like  cavity, 
with  iiTegular,  discolored,  full,  indurated,  and  everted 
edges,  and  a  base  whicli  is  usually  formed  of  hard 
granulations,  and  which  discharges  a  pui'if  orm,  bloody, 
foul,  or  ichorous  fluid. 

The  ulcer  of  carcinoma  differs  from  that  of  the 
other  mammary  neoplasms.  In  myxoma  and  sarcoma 
especially,  the  sore  may  be  deep  and  excavated,  and  its 
walls  composed  of  disintegrating  tumor  tissue ;  but 
the  ulcer  of  the  simple  growths  is  essentially  a  fun- 

*  From  a  married  and  prolific  female  fifty-two  years  of  age.  The  disease 
was  of  two  years'  duration,  was  traceable  to  heredity  and  trauma,  and  was  first 
noticed  two  years  after  the  menopause  as  a  small  tumor  beneath  the  retracted 
nipple  of  the  right  breast.  In  four  mouths  there  was  a  thin  and  bloody  dis- 
charge from  the  mammilla.  The  glands  of  the  corresponding  axilla  were  enlarged 
in  ten  months,  and,  in  twelve  months,  along  the  posterior  border  of  the  sterno- 
mastoid  muscle  and  in  the  supraclavicular  fossa.  At  the  same  time  a  nodule 
appeared  in  the  skin  of  the  upper  sternal  region.  In  fifteen  months  the  disease 
had  disseminated  itself  in  the  form  of  small  nodules  in  the  skin  over  the  greater 
part  of  the  right  chest,  a  tuber  appeared  in  the  left  mamma,  and  the  left  axil- 
lary glands  enlarged.  In  seventeen  months,  the  sternal,  left  mammary,  and  left 
axillary  tumors  ulcerated  spontaneously.  Her  health  had  failed  during  the  last 
six  months.  She  was  frequently  nauseated,  and  vomited  after  meals ;  the  appe- 
tite was  poor ;  and  she  suffered  great  pain  in  both  breasts,  the  neck,  and  the 
right  arm. 

As  a  result  of  caustic  applications  the  right  mamma  and  a  portion  of  the 
axilla  were  replaced  by  a  huge,  irregular,  deep,  funnel-like  ulcer,  with  everted, 
indurated  edges,  showing  here  and  there  evidences  of  cicatrization,  and  a  granu- 
lating surface,  which  bled  readily  on  changing  the  dressings.  The  mass  over 
the  sternum  consisted  of  two  large,  hard,  and  red  tubers  above,  and  of  a  super- 
ficial ulcer  below  as  large  as  a  silver  dollar.  The  outer  half  of  the  left  breast 
was  converted  into  a  densely  hard  tumor,  which  was  ulcerated  around  and  at  the 
outside  of  the  nipple,  the  latter  of  which  was  partially  destroyed.  The  skin  was 
infiltrated,  below  and  at  the  outer  side,  by  flattened  plates  of  carcinomatous 
material.  The  glands  of  the  left  axilla  formed  a  dense,  round  tumor,  as  large 
as  a  small  apple,  and  the  skin  was  superficially  ulcerated,  the  edges  of  the  sore 
being  excessively  hard  and  livid.  The  integument  of  the  sternal  border  of  the 
left  mamma,  around  the  sternal  growth,  and  over  and  below  the  right  clavicle, 
was  occupied  by  numerous  shot-like  and  lenticular  deposits,  a  few  of  which  were 
as  large  as  a  filbert.  The  supraclavicular  glands  and  the  glands  beneath  and 
over  the  right  sterno-mastoid  muscle  were  converted  into  secondary  tumors. 


154  FIXATION  TO  THE  CHEST. 

gating  one ;  that  is  to  say,  it  is  attended  mtli  the 
protrusion  of  pedunculated  masses,  which  are  not  at- 
tached to  the  sides  of  the  ulcer.  The  edges  of  the 
ulcer  are,  moreover,  smooth,  even,  and  free  from  dis- 
coloration and  infiltration.  Although  carcinoma  is 
said  to  throw  out  fungous  masses,  I  fancy  that  the 
statement  is  traditional,  as  I  cannot  find  a  single  ex- 
ample confii-med  by  minute  examination. 

I  have  witnessed  ulceration  as  early  as  the  ninth 
month,  but  it  usually  declares  itself,  on  an  average,  at 
20'2  months.  AViniwarter  fixes  the  mean  date  of  its 
appearance  at  17-7  months,  Oldekop  at  26*4  months, 
while  my  cases  averaged  16'6  months. 

Of  the  signs  of  local  infection  the  next  in  order 
of  frequency  is  invasion  of  the  deep  tissues,  as  indi- 
cated by  infiltration  of  the  pectoral  fascia,  or  the 
dissemination  of  distinct  nodules  in  the  pectoral  and 
intercostal  muscles  and  the  ribs,  which  corresponds  to 
the  fixation  or  adhesion  of  the  tumor  to  those  struc- 
tures. Of  315  cases,  in  which  this  point  is  noted,  the 
mamma  was  mobile  in  247,  and  more  or  less  closely 
adherent  in  68,  or  21'58  per  cent.  In  the  latter  class 
of  cases,  distinct  nodules  were  also  found,  on  opera- 
tion, in  1  case  out  of  every  14-1-  in  the  pectoral  mus- 
cles, in  1  out  of  every  73|-  in  the  intercostal  muscles, 
and  in  1  case  out  of  every  35f  in  the  ribs. 

Immobility  of  the  tumor  on  the  subjacent  tissues 
is  witnessed,  on  an  average,  in  22*6  months,  which  is 
the  mean  of  22*7,  23-4,  and  21*9  months  recorded, 
respectively,  by  Winiwarter,  Oldekop,  and  myself. 
Hence  it  ^\all  be  observed  that  fixation  of  the  growth 
ensues  8'5  months  after  adhesion  to  the  skin,  and  2*4 
months  after  ulceration.     It,  moreover,  usually  coex- 


CARCINOMA.  155 

ists  witli  infection  of  the  lympliatic  glands,  tlie  pres- 
ence of  wliicli  may  be  suspected,  if  they  cannot  be 
felt,  whenever  fixation  of  the  tumor  declares  itself. 

Amono*  the  more  uncommon  evidences  of  local 
dissemination  is  the  invasion  of  the  opposite  breast, 
which  is  noted  in  25,  or  3*65  per  cent.,  of  712  cases. 
It  is  a  late  sign,  appearing,  on  an  average,  at  32 -5 
months,  although  it  is  witnessed  as  early  as  four 
months,  and  as  late  as  six  years.  Of  20  cases  of 
which  I  have  the  full  particulars,  in  18  it  was  pre- 
ceded by  enlargement  of  the  glands ;  and  in  9  of  these 
there  were  also  nodules  in  the  skin,  and  ulceration 
was  present  in  the  original  tumor  in  5.  In  2  cases 
there  was  no  glandular  involvement,  but  in  both  the 
disease  was  preceded  by  cutaneous  tubers  and  by  ul- 
ceration of  the  primary  growth. 

From  the  preceding  facts  we  leam  that  carcinoma 
evinces  a  remarkable  disposition  to  infect  the  adja- 
cent tissues,  and  that  it  progresses  at  first  toward  the 
surface.  The  skin  is  invaded  in  68*92  per  cent. ; 
deep  attachments  ensue  in  21*90  per  cent. ;  and  the 
opposite  breast  suffers  in  3*65  per  cent,  of  all  in- 
stances. The  occurrence  of  local  dissemination  is, 
moreover,  indicated  by  the  formation  of  circum- 
scribed nodules  in  the  skin  in  10*61  per  cent.,  in  the 
subcutaneous  connective  tissue  in  8*39  per  cent.,  in 
both  of  these  situations,  as  in  the  cuirass  form  of  can- 
cer, in  1*95  per  cent.,  in  the  pectoral  muscles  in  7 
per  cent.,  in  the  intercostal  muscles  in  1*35  per  cent., 
and,  finally,  in  the  ribs  in  2*8  per  cent.  In  the 
order  of  the  date  of  their  appearance  we  may  look 
for  extension  to  the  superficial  fascia  and  skin  in  14 
months,  for  ulceration  in  20  months,  for  fixation  to 


156 


EXTENSION  TO  LYMPHATIC  GLANDS. 


tlie  cliest  in  22  montlis,  and  for  invasion  of  the  sec- 
ond breast  in  32  montlis.  These  facts  have  an  im- 
portant bearing  upon  the  question  of  operation,  to 
which  reference  will  again  be  made  under  the  head 
of  treatment. 

The  reproduction  of  carcinoma  in  the  associated 
lymphatic  glands  is  one  of  the  most  practically  inter- 
esting of  its  malignant  features,  and  exerts  a  decided 
influence  upon  the  course  of  the  disease,  upon  the  for- 
mation of  metastatic  deposits,  and  upon  the  final  issue 
after  operative  procedures.  As  I  have  already  stated, 
the  loose  collections  of  cells  are  partly  contained  in  the 
lymph  spaces  of  the  mammary  gland ;  and,  as  these  are 
the  radicles  of  the  lymphatic  vessels  one  can  readily 


Fig.  28. 


^K-^m 


'C^ 


r 


Carcinoma  of  the  Mammary  Gland,  the  Ground  Substance  of  which  is  stained 
WITH  Nitrate  of  Silver. — a,  a.  Alveoli  of  the  carcinoma  filled  with  cells. 
6,  b.  Lymph  spaces,  c.  Lymphatics,  showing  silver  staining  of  the  endothe- 
lium. 

conceive,  as  is  so  well  illustrated  by  fig.  28  from  Cor- 
nil  and  Ranvier,  how  easily,  and,  indeed,  )iow  inevita- 


CARCmOMA.  157 

bly,  tlie  young  epithelial  elements  are  transported  to 
the  lymphatic  glands  in  the  axilla  and  above  and  below 
the  clavicle,  where  they  implant  themselves,  prolifer- 
ate, and  reproduce  the  likeness  of  the  parent  growth. 
When  the  glands  are  contaminated,  they  delay  for  a 
certain  period,  on  the  one  hand,  metastatic  deposits, 
and,  on  the  other  hand,  constitute  new  foci  of  local 
and  general  infection.  Hence  the  cells  of  a  packet  of 
indurated  and  enlarged  glands  behave  precisely  like 
the  primary  tumor ;  that  is  to  say,  they  invade  the  sur- 
rounding tissues  and  infect  the  adjoining  glands  and 
the  viscera.  Just  how  often  the  glands  enlarge  as -a 
result  of  inflammatoiy  or  irritative  hyperplasia,  as  is 
witnessed  in  other  mammary  neoplasms,  I  am  unable 
to  say ;  but  it  is  very  certain  that  they  are  not  always 
carcinomatous,  since,  as  I  shall  show  hereafter,  several 
cases  are  on  record  in  which  they  have  been  left  be- 
hind during  operations,  in  which  they  have  subsided, 
and  in  which  the  patients  were  living  several  years — 
in  one  case,  indeed,  ten  years  afterwal'd— free  from 
disease. 

Out  of  657  cases  in  which  it  is  mentioned,  glan- 
dular contamination  was  witnessed  in  422,  or  64*23 
per  cent.,  when  the  patient  first  came  under  observa- 
tion. In  all  of  these  cases  the  axillary  glands  were 
inoculated,  and  along  with  these  the  supraclavicular 
glands  were  involved  in  27,  the  infraclavicular  in  5, 
and  the  cervical  in  3. 

Carcinomatous  degeneration  may  occur  as  early  as 
the  first  month,  or  may  be  delayed  for  seven  years. 
In  55  examples  I  myseK  have  never  witnessed  it  soon- 
er than  four  months,  nor  later  than  five  years,  even  in 
cases  of  atrophying  scirrhus.     About  1  case  in  every 


158  EXTENSION  TO  LYMPHATIC  GLANDS. 

4^  is  met  witli  in  the  first  six  montlis  ;  but  tlie  aver- 
age date  of  its  appearance  is  15'6  montlis,  or  14*7 
montlis  according  to  Winiwarter,  15  montlis  in  my 
o^vn  experience,  and  16'5  months  in  tliat  of  Oldekop. 
Hence  it  a^^pears  one  month  after  invasion  of  the  skin, 
than  which  it  is  only  4-69  per  cent,  less  frequent ;  and 
it  is  met  with  before  ulceration,  deep  adhesions,  and 
extension  to  the  opposite  breast.  In  exceptional  in- 
stances it  is  even  observed  before  the  primary  tumor 
is  noticed. 

A  point  of  interest,  and  it  is  one  which  must  have 
attracted  the  attention  of  every  siu'geon,  is,  that  the 
seat  of  the  carcinoma  exerts  no  influence  upon  the  fre- 
quency, or  the  date  of  the  appearance,  of  the  lym- 
phatic tumor.  In  other  words,  the  glands  are  not  in- 
volved earlier  or  oftener  when  the  original  growth  is 
near  the  axilla,  or  when  it  occupies  the  inner  peri- 
pheiy  of  the  mamma. 

While  it  is  a  well-known  fact  that  the  cases  unin- 
fluenced by  operation,  in  which  the  gland  contamination 
does  not  show  itself  until  late,  pursue  a  more  chronic 
course,  and  do  not  perish  nearly  so  quickly  as  those  in 
which  the  glands  are  infiltrated  early  in  the  affection, 
the  statistics  of  Winiwarter  and  Oldekop  show  con- 
clusively not  only  that  the  chances  of  removing  the 
entire  disease  are  greatly  lessened  when  the  glands 
are  enlarged,  but  that,  as  in  the  former  instance,  the 
patients  succumb  much  sooner,  and  that  recurrence  is 
far  more  rapid.  Thus,  of  136  subjected  to  opera- 
tion, 43  were  free  from  glandular  tumors,  and  their 
average  life  from  the  first  observation  of  the  disease 
to  the  fatal  issue  was  52*7  months.  Among  these  pa- 
tients local  reproduction  ensued,  on  an  average,  in  8 


CARCINOMA.  159 

montlis.  Of  93  in  whom  both  the  breast  and  the 
glands  were  removed,  the  mean  life  was  39*3  months, 
and  the  average  time  of  recurrence  was  1*9  months. 
Hence  the  foiTner  lived  13*4  months  longer  than  the 
latter,  and  when  there  was  recurrence  it  appeared  6-1 
months  later. 

The  number  of  glands  involved  is  sometimes  enor- 
mous, being  greater  even  than  the  study  of  nonnal 
anatomy  leads  one  to  conceive.  Thus,  from  a  woman 
forty-eight  years  of  age,  in  whom  the  disease  had  exist- 
ed eighteen  months,  I  saw  Professor  Gross  remove, 
along  mth  the  breast,  iifty  glands,  which  varied  in  size 
from  a  small  shot  to  a  hazel-nut.  On  her  return  to 
the  clinic,  ten  weeks  subsequently,  the  disease  was 
found  to  have  recurred  at  the  edge  of  the  pectoral 
muscle,  in  the  axilla,  and  in  the  supraclavicular  glands. 

In  the  majority  of  instances  the  glands  are  sejDa- 
rate  and  distinct.  In  others  they  constitute  a  densely 
hard,  conglomerate,  knobby  mass;  while,  now  and 
then,  the  disease  is  confined  to  a  single  gland,  which 
may,  as  in  a  case  of  my  own,  measure  three  inches  and 
a  quarter  by  one  inch  and  three-quarters  in  its  long 
and  short  diameters. 

After  contamination  of  the  lymphatic  glands  the 
cells  pass  into  the  circulatory  system  through  the 
thoracic  and  right  lymphatic  ducts,  are  transported 
to  the  viscera,  the  bones,  and  other  tissues,  in  which 
they  proliferate,  reproduce  the  likeness  of  the  primary 
gro"\vth,  and  in  this  way  develop  metastatic  deposits 
or  gTowths.  General  dissemination  may,  however, 
manifest  itself  without  antecedent  glandular  infec- 
tion, but  such  a  course  is  exceptional.  Thus,  of  39 
post-mortem  inspections  in  which  systemic  secondary 


160  METASTATIC  DEPOSITS. 

tumors  were  discovered,  the  intervening  glands  were 
involved  in  34,  or  87*17  per  cent.;  in  2,  or  5*13  per 
cent.,  there  were  merely  tubers  in  the  skin  and  pectoral 
muscle ;  while  in  3,  or  7'69  per  cent.,  there  were  no 
primary  complications  whatever.  Hence,  in  about  1 
case  in  every  8,  metastasis  occurs  mthout  contamina- 
tion of  the  glands ;  but  it  should  be  remembered  that 
the  glands  may  be  overlooked,  and  that,  as  happens 
in  medullary  carcinoma,  the  infection  may  take  place 
through  the  bloodvessels. 

Of  the  frequency  of  metastatic  deposits  our  knowl- 
edge is  most  uncertain,  for  the  reason  that  it  is  by 
no  means  easy  to  follow  our  cases  or  to  obtain  post- 
mortem examinations.  My  own  observations  in  this 
respect  are  worthless,  as  I  was  enabled  to  make  a 
section  in  only  one  case,  it  being  one  of  atrophying 
scirrhus  w^hich  had  lasted  for  upward  of  seventeen 
years,  and  in  which  I  detected  tumors  in  the  lungs, 
the  pleura,  the  bronchial  and  mediastinal  glands,  and 
the  right  kidney.  The  tables  of  Winiwarter,  Olde- 
kop,  and  Henry,  however,  contain  39  cases  of  general 
dissemination  confirmed  by  section  after  death,  and 
44  cases  in  which  that  condition  was  determined  by 
well-marked  symptoms  during  life.  They  were  dis- 
tributed as  follows ; 

Died  without  operation  70  Metastases  in,  10  Presumed  metastases  in,  6 
Died    from  the   effects 

of  operation 87  "  8         "  "  0 

Died    with    recurrence 

after  operation 217  "  21  "  "  38 

374  39  '        44 

Hence,  of  374  patients,  metastatic  deposits  had 
formed,  or  were  presumed  to  have  formed,  in  .83,  or 
22*19  per  cent.     As  indicated  by  section,  they  were 


CARCINOMA.  161 

present  in  39  out  of  78,  or  precisely  50  per  cent. 
This  latter  point  is  interesting,  as  it  denotes  that  death 
ensues  in  one-half  of  all  cases  merely  from  the  bane- 
ful effects  exerted  upon  the  nutrition  of  the  patient 
without  cancerous  degeneration  of  the  viscera. 

The  date  at  which  metastases  form  varies  from 
five  months  to  eight  years.*  Out  of  every  100  cases 
24  will  be  found  within  a  year ;  3  in  from  thirteen  to 
eighteen  months;  18  in  from  nineteen  to  twenty-four 
months ;  27  in  from  twenty-five  to  thirty -six  months ; 
and  28  after  three  years.  Winiwarter,  Henry,  and 
Oldekop  compute  the  average  date  of  death  fi'om 
metastases  from  the  first  appearance  of  the  disease, 
respectively,  at  23*7,  31-7,  and  38*2  months,  so  that  the 
general  mean  is  31*2  months,  or  15*6  months  after  glan- 
dular reproduction.  The  fact  of  the  rare  occurrence 
of  visceral  deposits  between  the  thii-teenth  and  eight- 
eenth months  may  be  explained  by  the  comparative 
freedom  of  the  glands  from  infection  at  that  period. 

In  the  39  cases '  in  which  sections  were  made  after 

'The  remarkable  symmetrical  case  of  Billroth,  referred  to  at  page  146,  which 
developed  during  pregnancy,  and  ran  its  course  in  six  weeks,  is  not  included  in 
this  computation. 

*  With  a  viaw  to  determine  the  relative  frequency  of  the  seats  of  secondary 
deposits  from  a  larger  number  of  cases,  I  have  obtained  the  following  results  by 
adding  to  the  39  cases  89  compiled  by  Mr.  H.  Arnott.  Mr.  II.  Morris,  and  Mr.  A. 
Clark,  Surgical  Registrars  to  the  Middlesex  Hospital,  whose  accuracy  cannot  be 
questioned,  and  published  in  the  Trans.  Path.  Soc.  of  Londo  i,  vol.  xxvii,  p.  264: 
Thus,  of  1^8  post-mortem  examinations,  secondary  tumors  were  discovered  in  the 


Per  cent. 

Per  een 

Axillary  glands  in 

115  or  89-94 

Liver, 

in 

55  or  42-96 

Other  glands,      " 

30  "  23-43 

Pancreas, 

1   "     0-78 

Pleura,                 " 

30  "  23-43 

Spleen, 

3  "     2-34 

Pericardium,        " 

3  "     2-34 

Kidney, 

5  "     3-90 

Peritoneum,         " 

3  "     2-34 

Adrenal, 

2  "     1-56 

Brain,                    " 

3  "     2-34 

Ovary, 

7  "     5-46 

Lung,                    " 

28  "  21-87 

Uteriis, 

2  "     1-56 

tF.sophagus,         " 

1    "     0-78 

Bladder, 

1  "     0-78 

Storaacli,              " 

5  "     3-90 

Bones, 

9  "     7-02 

Jejunum,             " 

1  "     0-78 

Muscles, 

2  "     1-56 

11 

162 


CANCEROUS  CACHEXIA. 


death,  tlie  relative  frequency  of  the  seats  of  the  sec- 
ondary deposits  is  shown  by  the  following  statement : 


Dora  mater  in  . .  . 

...  3  cases. 

Kidney 

in. 

. .   3  cases 

Pleura           "  . . . 

...9     " 

Adrenal 

. .   1  case. 

Pericardium  "  . . . 

...  1  case. 

Ovary 

. .  2  cases 

Brain             "  . . . 

...   3  cases. 

Uterus 

. .  1  case. 

Lung              "  . . . 

...14     " 

Bladder 

..  1     " 

(Esophagus   "  . . . 

...   1  case. 

Bones 

. .  4  cases 

Stomach        "  . . . 

...  4  cases. 

Muscles 

..2     " 

Jejunum        "  . . . 

...   1  case. 

Bronchial 

glands 

..3      " 

Liver             "  . . . 

...  20  cases. 

Mesenteric  glands 

..2     " 

Spleen           "  . . . 

...   1  case. 

While  in  sarcoma  the  lungs  and  the  bones  are  the 
most  common  seats  of  the  secondary  deposits,  the 
liver  being  affected  only  one-half  as  frequently  as  the 
lungs,  the  digestive  organs,  the  lungs,  and  the  serous 
membranes  are  the  seats  of  predilection  of  cancer; 
and  the  liver  is  attacked  25*41  per  cent,  more  fre- 
quently than  in  the  former  disease.  The  liability  of 
the  liver  to  infection,  even  to  a  greater  extent,  has 
been  remarked  by  other  observers,  and  affords  a  strik- 
ing contrast  to  that  of  the  lungs,  which  might  natu- 
rally be  expected  to  be  the  most  frequently  tainted. 

With  the  progress  of  the  local  and  general  disease 
the  so-called  "  cancerous  cachexia "  is  established. 
This  is  nothing  more  than  the  general  failing  of  the 
powers,  such  as  is  witnessed  in  many  other  maladies, 
attended  mth  loss  of  blood,  offensive  and  exhausting 
discharge,  and  suffering,  and  is  due  to  the  improper 
performance  of  the  functions  of  the  viscera,  and  the 
consequent  ill  effects  produced  upon  the  general  nu- 
trition, as  indicated  by  wasting,  loss  of  aj)petite  and 
strength,  nausea,  sallowness,  and  a  quick  and  feeble 
pulse.     As  we  have  just  seen,  death  occ\u's,  as  demon- 


CARCINOMA. 


163 


strated  by  post-mortem  inspection,  in  an  equal  num- 
ber of  cases,  whether  there  be  visceral  deposits  or 
not.  The  latter  succumb  from  the  intensity  of  the 
local  disease  and  its  effects ;  the  former  from  the 
effects  of  metastases,  as  indicated  by  symptoms  which 
denote,  implication  principally  of  the  liver,  lungs, 
pleura,  digestive  organs,  and  nervous  system. 

The  foreGToino;  facts,  deduced  from  the  morbid 
changes  which  ensue  in  carcinoma,  clearly  demonstrate 
that  the  prognosis  of  the  affection  is  eminently  unfa- 
vorable. This  statement  becomes  the  more  apparent 
from  the  study  of  the  cases  which  pursue  a  natural 
course  and  of  those  subjected  to  the  knife.  In  this 
study  are  included  the  duration  of  life  in  each  class 
and  the  influence  of  the  operation  on  the  progress  of 
the  disease. 

Of  616  cases,  97  ran  a  natural  course,  and  519  un- 
derwent operation. 

Of  the  97,  70  were  dead,  with  visceral  deposits  in 
10,  and  presumed  metastases  in  6  ;  13  were  still  alive 
in  bad  condition  ;  and  in  14  the  fate  was  unknown. 

Of  67  of  these  in  which  the  data  was  noted, 

30*82  per  cent,  died  in  between    5  and  12  months. 


33-72 

'        12 

24 

11-37 

24 

36 

9-87 

36 

48 

.  7-91 

48 

60 

3-48 

'         60 

72 

1-28 

'        died  after  6 

years. 

The  average  duration  of  life  was  27"1  months, 
having  been,  according  to  Oldekop,  22*6  months,  ac- 
cording to  Henry,  26  months,  and,  according  to  Wini- 
warter, 32*9  months. 

224  died  after  operation  with  recurrence  of  the 


164:  PROGNOSIS. 

disease,  and  in  21  of  tliese  metastases  were  discov- 
ered, and  were  suspected  in  38.     Of  this  number, 

10-50  per  cent,  died  in  between    6  and  12  months. 

33-00  "  "           "         12  "  24       " 

24-03  "  "           "        24  "  36  " 

9-95  "  "          "        36  "  48  " 

Y-91  "  "           "        48  "  60  " 

5-04  "  "           "         60  "  72  '■'■ 

9*51  "  died  after  6  years. 

The  average  duration  of  life  in  these  224  patients 
was  39  months;  and  the  computations  of  Oldekop, 
Henry,  and  Winiwarter  are  singularly  alike  on  this 
point,  being,  respectively,  38*1,  39*3,  and  39*6  months. 
A  comparison  of  the  two  tables  shows  that  the  course 
of  the  disease  is  retarded  by  the  removal  of  the 
growth ;  and  a  comparison  of  the  two  averages  in- 
dicates that  operation  adds  twelve  months  to  the  life 
of  the  patient. 

Not  only  is  life  prolonged  by  operation,  but  the 
removal  of  the  entire  breast,  along  with  any  infected 
glands  that  may  be  discovered,  that  is  to  say,  thorough 
operations,  results  in  peimanent  recovery  in  9*05  per 
cent,  of  all  cases.  As  we  have  already  seen,  death 
from  metastases  occurs  at  31 '2  months,  and  the  aver- 
age date  of  death  of  those  who  succumb  without 
or  with  oj)eration  is  33  months.  We  shall,  moreover, 
see  presently  that  local  recurrence  of  the  disease  after 
three  years  is  met  with  in  only  one-half  of  1  j^er  cent, 
of  all  cases.  Hence  a  radical  cure  may  be  assumed 
if  the  patient  has  survived  the  disease  over  three 
years  without  local  or  general  recuiTence  after  the 
last  operation,  or  if  she  has  died  of  some  intercurrent 
malady  under  the  same  conditions. 

Of  519  cases  submitted  to  the  knife,  43  were  still 


CARCINOMA.  165 

living,  and  4  had  died.  Of  these  47,  recurrent 
growths  were  removed  in  six ;  and  there  was  freedom 
from  disease  after  the  last  operation  in 

14  for  between  3  years  and  2  mouths  and  3  years  and  11  months. 

8  "  4     "  u  4  u  6        " 

7  "  5     "  "  5  "  9        " 

3  for  6     " 

4  for  between    7     "  «      7  "  9        " 

1  for  8     "      and  9  months. 

2  for  between  9  "  "6  "  "  9  "  10  " 
2  "  10  "  "  1  month  "  10  "  10  " 
2  "  11  "  "  11  "  9  " 
1           for         12  " 

1  "  13     "      and  8  months. 

1  "  15     "        "    7        " 

The  average  time  of  cure  was  5  years  and  9 
months,  and  the  disease  had  existed  before  operation, 
on  an  average,  for  18'4  months.  The  cases  were  not 
selected  in  order  that  the  best  possible  results  might 
be  obtained,  since  I  find  that,  of  44  in  which  the 
nature  of  the  operation  is  noted,  the  mamma  was  en- 
tirely removed  and  the  axilla  was  cleared  out  in  18, 
and  the  breast  alone  was  amputated  in  26,  although, 
in  three  of  these,  enlarged  glands  were  left  intact  in 
the  axilla,  and  yet  the  cure  was  assured  at  the  end, 
respectively,  of  5  years  and  9  months,  6  years  and  1 
month,  and  10  years  and  10  months.  The  practical 
deductions  which  can  be  gathered  from  such  data  are 
so  clear  that  they  do  not  require  comment. 

As  a  further  proof  of  the  influence  exerted  upon 
the  duration  of  life  by  radical  operations,  attention 
may  be  called  to  the  fact  that  nearly  one-third  were 
free  from  disease  after  the  lapse  of  six  years ;  while,  of 
the  67  patients  in  whom  no  operation  was  practiced, 
only  one  survived  after  that  period. 


166  PROGJ^OSIS. 

Sir  James  Paget/  in  speaking  of  tlie  duration  of 
life  after  operation,  says  :  "  I  am  not  aware  of  a  sin- 
gle clear  instance  of  recoveiy — of  sucli  recoveiy,  that 
is,  as  that  the  j)atient  should  live  for  more  than  ten 
years  free  from  the  disease."  Applying  this  severe 
test,  an  examination  of  the  table  will  show  that 
rather  more  than  1  in  6  fulfils  this  condition.  It 
must,  however,  be  borne  in  mind  that  at  the  time  he 
penned  his  words  the  influence  of  the  writings  of  the 
late  Mr.  Moore,"  of  the  Middlesex  Hospital,  had  not 
been  felt  in  England,  whereas  the  latter  surgeon's 
practical  conclusions  were  fully  canied  out  in  Ger- 
many, Denmark,  and  Austria. 

In  addition  to  the  47  permanent  cures  after 
operation,  43  cases  were  alive  mthout  recurrence 
from  the  last  operation  for  a  period  which  varied 
from  3  weeks  to  3  years,  or  13'2  months  on  an 
average. 

If  the  patient  survives  an  operation,  local  recur- 
rence of  the  disease  may  be  looked  for.  Of  519  op- 
erations, 87  died  from  its  immediate  eifects,  thereby 
leaving  432  cases  for  the  consideration  of  the  question 
of  local  reproduction.  Of  these  cases,  64  are  devoid 
of  further  history,  having  been  lost  sight  of  imme- 
diately after  recovery  ;  so  that  of  368  patients 

90  were  cured,  but  18  had  had  recurrences. 
31  were  alive  with  recurrence. 
23  had  recurrence,  but  further  details  are  wanting. 
158  died  with  recurrence,  but  with  no  evidence  of  metastases. 
38    "      "  "  and  with  presumed  metastases. 

21    "      "  "  "      "      actual  metastases. 

T    "       "  "  but  the  question  of  mej;astase9  is  doubtful. 

'  Op.  dt.,  p.  649. 

'  On  the  Influence  of  Inadequate  Operations  on  the  Theory  of  Cancer. — Med.- 
Chir.  Trans.,  vol.  xxxii,  2d  ser.,  ISGY,  p.  245. 


CARCINOMA. 


167 


It  will  thus  be  perceived  that  the  tumor  repro- 
duced itself  locally  in  296,  or  80*97  per  cent.,  after 
368  operations,  a  fact  which  accords  ^vith  the  infiltra- 
ting nature  of  the  disease,  as  observations  during  life 
and  during  operative  procedures,  as  we  have  previous- 
ly seen,  demonstrate  infection  of  the  superfcial  and 
subjacent  tissues  in  90*82  per  cent,  of  all  instances. 

In  203  cases,  analyzed  by  Winiwarter  and  Olde- 
kop,  the  periods  of  recurrence  were  as  follows : 

Within  15   days    in  39  cases. 
"        1  month  "  50      " 


From    end     of 

1st 

to 

end  of 

3d 

"  38 

"  beginning  '' 

4th 

11 

((       a 

6th 

"  18 

a             ((           u 

Vth 

i; 

u      u 

9th 

"  16 

a             (.           u 

10th 

(( 

U         (( 

12th 

"  19 

u             u           u 

13th 

u 

a      u 

18th 

•'     9 

(C               u            u 

19th 

ic 

u      u 

24th 

"     6 

((                 (I              u 

25th 

u 

u      u 

30th 

"     3 

il.                  il.               u 

31st 

u 

((        u 

36th 

"     3 

After  3  years 

"     2 

The  table  shows  that  more  than  one-half,  or  63 
per  cent.,  of  the  recurrences  took  place  in  3  months, 
while  after  12  months  there  were  only.  23,  or  11*65  per 
cent.,  and  of  these  there  were  only  2  after  3  years. 
The  average  period  for  all  cases  is  5*3  months.  The 
cases  of  local  reproduction  within  the  first  quarter 
of  a  year  were  doubtless  examples  of  continuous 
growth,  rather  than  of  recurrence,  and  merely  indicate 
that  the  original  disease  was  not  thoroughly  removed. 
They,  moreover,  lead  to  the  belief  that,  if  recuiTence 
does  not  ensue  in  that  time,  the  chances  for  the  pa- 
tient are  relatively  good,  and  that  the  prognosis  is  all 
the  more  favorable  as  the  period  of  freedom  from  signs 
of  local  contamination  prolongs  itself.   The  exceptional 


168  RECURRENCE. 

cases  prove  tlie  rule  that  the  patient  is  safe  from  re- 
production after  3  years  from  the  date  of  operation. 
When  studied  with  regard  to  gland  complications,  the 
cases  show,  contraiy  to  the  generally  received  opinion, 
that  total  extirpation  of  the  breast  alone  is  followed 
by  recurrence,  on  an  average,  in  3'1  months,  and  that 
it  ensues,  on  an  average,  in  7*5  months  after  amputa- 
tion of  the  mamma  with  the  diseased  axillary  glands. 
This  point,  with  the  one  previously  mentioned,  name- 
ly, that  recurrence  in  the  axilla  is  far  more  frequent 
after  removal  of  the  breast  alone  than  when  the  glands 
are  simultaneously  removed,  demonstrates  that  the 
wiser  course  is  to  explore  the  axilla,  even  if  its  glands 
cannot  be  detected  from  without. 

In  194  cases,  in  which  the  point  is  noted,  the  re- 
current local  disease  was  seated 

,  Per  cent. 

In  the  cicatrix,  remains  of  mamma,  or  vicinity,  alone  in  112,  or     57"72 

"    "         "  "  "  "  and  glands  "     48,  "      24*74 

"    "  glands  alone  "     28,  ''      14-43 

"    "  opposite  breast  "       6,  "       3-09 

Its  locality,  as  influenced  by  the  operation  prac- 
ticed in  117  cases,  was  as  follows: 

1.  Partial  or  total  extirpation  of  the  mamma  without  the  glands,  47  cases. 

Recurrence  in  or  near  the  cicatrix,  23  cases,  or  48'93  per  cent. 
"  the  glands  alone,  9  "    1914       " 

"  cicatrix  and  glands,    15  "   31-91       " 

2.  Amputation  of  the  breast  with  extirpation  of  the  glands,  70  cases. 

Recurrence  in  or  near  the  cicatrix,  48  cases,  or  68-57  per  cent. 
"  "■  the  glands  alone,         5  "        7*14      " 

"  "  both  places,  17  "      24-28       " 

It  will  thus  be  seen  that  the  axilla  was  far  more 
frequently  the  seat  of  recurrence,  or  rather  spread,  of 
the  disease,  after  extirpation  of  the  breast  alone,  than 


CARCINOMA.  169 

when  tlie  glands  and  breast  were  botli  removed. 
Hence,  by  clearing  out  that  cavity  in  all  operations, 
we  may  naturally  expect  to  diminish,  if  not  prevent, 
further  local  dissemination,  and  remove  foci  of  gen- 
eral infection. 

A  review  of  the  facts  contained  in  the  preceding 
pages  in  regard  to  the  prognosis  of  carcinoma,  or  the 
duration  of  life,  as  influenced  by  permitting  the  dis- 
ease to  pursue  its  course  without  surgical  interven- 
tion, or  by  endeavoring  to  stay  it  by  a  resort  to  the 
knife,  leads  us  to  adopt  the  following  conclusions  : 

That  when  left  to  itself  carcinoma  inevitably  kills, 
by  its  baneful  consequences  as  a  local  disease,  or  by 
its  remote  multiplication. 

That  about  one  in  six,  or  16-77  per  cent.,'  of  the 
patients  die  of  the  operation  itself ;  but  that  the  risk 
is  not  so  great  as  to  forbid  interference,  since  it  adds 
twelve  months  to  the  life  of  the  patient. 

That  thorough  operations  definitely  cure  9*05 '  per 
cent,  of  all  patients,  or  more  than  half  as  many  as  it 
destroys. 

That  the  patient  is  safe  from  reproduction  if  three 
years  have  elapsed  since  the  operation ;  and, 

That,  finally,  recurrence  may  be  delayed  for  sev- 
eral months,  or  be  prevented  altogether,  by  clearing 
out  the  axilla  at  the  same  time  that  the  entire  breast 
is  removed. 

The  diaofnosis  of  carcinoma  of  the  breast  in  its 
early  stages,  or  before  there  is  implication  of  the  sur- 

'  The  mortality  is  excessive,  because  a  very  large  proportion  of  the  opera- 
tions were  radical. 

'^  Or,  if  wc  deduct  64  patients,  of  whom  nothing  further  is  known,  the  cures 
reach  10'32  per  cent. 


170  DIAGNOSIS. 

rounding  tissues  and  the  lymphatic  glands,  is  based 
upon  the  age  of  the  patient,  the  average  being  forty- 
eight  years,  the  dimpling  of  the  skin,  the  retraction 
of  the  nipple,  the  immobility  of  the  solitary  tumor  in 
the  mamma,  or,  if  it  be  seated  at  the  periphery,  its 
intimate  attachment,  its  nodular  outline,  its  small 
size,  its  slow  growth,  and  its  stony  hardness ;  and  the 
diagnosis  is  strengthened  if  there  be  a  history  of 
heredity,  and  if  there  were  antecedent  discharge  from 
the  nipple  and  eczema  or  psoriasis  of  that  body. 
When  the  disease  has  made  some  progress,  or  after 
the  thirteenth  month  of  its  existence,  the  adhesion 
and  invasion  of  the  skin,  the  enlargement  and  indu- 
ration of  the  associated  lymphatic  glands,  the  occur- 
rence of  ulceration  and  fixation  to  the  chest,  and  the 
impaired  nutrition  of  the  patient,  constitute  a  group 
of  signs  which  cannot  be  mistaken. 

From  this  general  course  of  carcinoma  there  are 
certain  deviations  which  may  be  ascribed  to  histolog- 
ical peculiarities,  since  the  following  study  of  medul- 
lary, colloid,  and  atrophying  cancer  shows  that  the 
intensity  of  the  disease  is  modified  by  structural  ab- 
errations. All  of  these  varieties  j)ossess  certain  fea- 
tures in  common,  but  the  different  degrees  of  ma- 
lignity are  sufficiently  pronounced  to  warrant  a  sep- 
arate examination  of  their  individual  characteristics ; 
and  this  is  the  more  necessary,  as  the  medullary  and 
colloid  forms  are  usually  confounded  with  medullary 
sarcoma  and  meduUaiy  myxoma. 

Medijllaey  Carcinoma. — Medullaiy,  or  tuberous, 
carcinoma,  as  it  is  denominated  by  Birkett  and  Bry- 


CARCINOMA.  171 

ant,  is  described  by  most  autliors  as  being  enclosed 
in  a  distinct  capsule  ;  and  they  distinguisli  it  from 
ordinary  cancer  by  its  occurrence  at  a  comparatively 
early  age,  by  its  more  rapid  growth  and  larger  vol- 
ume, by  its  soft  consistence,  by  the  marked  enlargement 
of  the  subcutaneous  veins,  by  the  natural  state  of  the 
nipple,  by  the  rare  and  late  adhesions  and  contamina- 
tion of  the  lymphatic  glands,  by  the  frequent  forma- 
tion of  ulcers  which  protrude  bleeding  masses  beyond 
the  surrounding  level,  and  by  its  very  rapid  course. 

While  it  is  true  that  some  of  these  statements  are 
correct,  it  is  very  evident  that  the  life  history  of  me- 
dullary carcinoma  is  lost  in  that  of  medullary  sarcoma. 
Medullary  carcinoma  is  never  encapsuled,  and  the 
presence  of  a  limiting  envelope  is,  of  itself,  sufficient 
to  decide  aQ:ainst  it.  The  followdns^  account  of  its 
general  pathology  is  based  upon  a  study  of  22  cases, 
derived  from  various  sources. 

It  occurs  as  early  as  29  and  as  late  as  69  years,  the 
average  being  50.  20  per  cent,  of  all  cases  are  met 
with  before  40,  and  80  per  cent,  after  that  age ;  while 
exactly  one-half  occur  after  50. 

Medullaiy  carcinoma  growls  rapidly,  and  the  vol- 
ume of  a  child's  head  in  three,  five,  six,  or  eight 
months,  or  even  in  five,  six,  or  eight  wrecks,  is  not  un- 
common ;  but  it  never  attains  the  bulk  which  is  some- 
times witnessed  in  sarcoma.  Its  consistence  is  soft 
and  elastic,  or  even  fluctuating,  so  that  it  may  be 
mistaken  for  an  abscess,  in  66*66  per  cent,  of  all  cases. 
In  the  remaining  third  the  tumor  is  hard,  or  finn, 
with  a  certain  degree  of  elasticity.  Like  sarcoma, 
but  unlike  ordinary  cancer,  its  outline  tends  to  lobu- 
lation. 


172  MEDULLARY  CARCINOMA. 

The  subcutaneous  veins  are  prominent  in  9*09  per 
cent,  of  all  cases,  and  the  nipple  is  retracted  in  33-33 
per  cent. 

The  lymphatic  glands  are  infected  in  59*02  per 
cent.,  and  theii'  taint  may  show  itself  as  early  as  thi-ee 
weeks,  or  may  be  absent  for  nearly  five  years. 

The  skin  is  discolored  and  adherent  in  52*92  per 
cent.,  and  it  also  contains  distinct  nodules  in  5*88 
per  cent,  of  these  cases.  Ulceration  is  met  with  in 
18*18  pea-  cent.,  and  the  sore  is  deep  and  excavated, 
and  liable  to  hemorrhage,  but  it  does  not  fungate. 

The  tumor  is  fixed  to  the  chest  in  29*41  per  cent, 
of  all  instances,  and  in  11*76  per  cent,  of  these  cir- 
cumscribed tubers  exist  in  the  pectoral  muscles.  Both 
breasts  are  affected  in  9*09  per  cent,  of  all  cases. 

Of  the  four  cases  that  ran  a  natural  course,  all 
were  dead,  on  an  average,  in  eight  months  from  the 
first  appearance  of  the  disease,  the  period  having  been, 
respectively,  five  weeks,  six  wrecks,  five  months,  and 
two  years.  Post-mortem  inspection  in  two  cases  dis- 
closed metastatic  tumors  in  the  lung  and  pleura  in 
one,  and  in  the  thyroid  gland,  pericardium,  liver, 
omentiun,  and  kidney,  in  the  other. 

Four  died  from  the  operation  itself.  The  average 
life  was  twenty-seven  months,  and  the  only  post-mor- 
tem examination  that  was  made  showed  deposits  in 
the  liver  and  pleura. 

Of  nine  patients  who  died  with  local  recurrence 
after  operation,  the  average  life  was  sixteen  months 
and  a  half,  and  the  tumor  reproduced  itself  in  three 
months  on  an  average.  In  the  single  post-mortem 
section,  the  liver,  stomach,  and  ovary  were  found  to 
be   occupied   by   secondary   growths.      Three   cases 


CARCmOMA.  173 

were  subjected  to  tlie  knife ;  but  further  details  are 
wanting.  Their  average  life,  up  to  the  date  of  opera- 
tion, was  twenty-two  months  and  a  third. 

Finally,  two  were  cured ;  that  is,  they  remained 
well  and  free  from  recurrence,  respectively,  for  four ' 
and  five '  years  after  surgical  operation.  In  the  first 
case  the  breast  was  amputated,  and  the  enlarged  ax- 
illary glands  were  extirpated ;  while  in  the  second 
the  breast  alone  was  removed,  there  having  been  no 
primary  complications. 

From  the  fores^oinsf  account  it  follows  that  medul- 
lary  carcinoma  is  the  most  malignant  of  all  the  tu- 
mors of  the  mamma,  since  local  recun'ence  ensues 
within  three  months  after  removal  in  81*81  per  cent. 
of  all  cases;  metastatic  growths  are  always  discov- 
ered on  post-mortem  insj)ection,  and  are  preceded  by 
taint  of  the  glands  of  the  axilla  in  three-fourths  of 
the  instances ;  and  the  total  duration  of  life  T^dthout 
surgical  intervention  is  only  eight  months.  Life  may 
be  doubled,  however,  and  a  positive  cure  result  in 
18.18  per  cent,  of  all  cases,  by  an  early  resort  to  the 
knife,  even  if  the  axillary  glands  are  extensively  con- 
taminated. 

The  distinction  between  meduUaiy  carcinoma  and 
medullary  sarcoma  may  be  made  by  paying  attention 
to  the  follomng  points  in  their  afiinities  and  contrasts. 

Medullary  sarcoma  occurs,  on  an  average,  eight 
years  earlier,  is  more  common  before  the  fortieth  year 
by  33  per  cent.,  and  is  even  seen  as  early  as  the  age 
of   sixteen.      The    subcutaneous  veins   are    enlarged 

'  Henry,  op.  cit.,  case  27. 

*  Satterthwaite  and  Porter,  Observations  in  One  Hundred  Cases  of  Carcinoma, 
Reprint,  New  York,  IS19,  p.  96. 


174  COLLOID    CARCINOMA, 

5*19  per  cent.,  and  ulceration  occurs  3*24  per  cent, 
more  frequently,  and  the  tissue  of  the  tumor  invari- 
ably protrudes  through  the  sore.  The  skin  adheres 
in  24-35  per  cent,  less  of  cases,  while  the  nipple  is 
never  retracted,  nor  are  the  axillary  glands  ever  con- 
taminated. Its  course  is  far  more  chronic,  and  it  may 
last  five  or  six  years  before  removal  is  demanded. 
The  average  life  without  operation  is  7  months,  and 
with  operation,  30  months,  or  13|  months  longer  than 
in  medullary  carcinoma.  Local  reproduction  is  wit- 
nessed in  61*33  per  cent.,  and  metastases  in  57*14  per 
cent.,  against  81*81  per  cent,  and  100  per  cent,  re- 
spectively, for  medullary  carcinoma. 

Colloid  CARCiT^oirA,  as  based  upon  a  critical  anal- 
ysis of  13  cases,  is  distinguished  by  its  chronic  course, 
by  the  late  and  infrequent  degeneration  of  the  glands, 
by  its  freedom  from  recurrence,  and  by  the  protract- 
ed appearance  of  metastatic  deposits,  features  which 
make  it  the  least  malignant  of  the  cancers.  Its  com- 
parative immunity  from  local  and  general  dissemina- 
tion may  be  ascribed  to  the  biological  changes  in  its 
cells,  the  greater  portion  of  the  protoplasm  of  which 
is  converted  into  colloid  material,  which  acts  the  part 
of  an  intercellular  substance  and  prevents  or  retards 
the  migration  of  the  cells  into  the  adjacent  tissues 
and  their  transference  along  the  lymphatics  to  the 
associated  glands  and  the  \dscera. 

It  is  met  with  as  early  as  28  and  as  late  as  66 
years,  the  average  being  45 ;  76*93  per  cent,  occur 
after  the  fortieth  year,  and  46*15  per  cent,  after  the 
age  of  fifty. 

It  increases  very  slowly,  and  the  volume  of  a  fist 


GARCmOMA.  175 

is  exceptional,  tliat  of  a  lien's  ^gg  being  the  rule, 
and  it  may  require  ,  fourteen  years  to  attain  that 
size. 

Its  consistence  is  hard,  only  7*69  per  cent,  being 
soft  and  elastic,  and  then  only  at  the  more  prominent 
bosses.     Its  outline  is  nodular  or  bossed. 

The  subcutaneous  veins  are  somewhat  prominent 
in  23*07  per  cent.  The  nipple  is  retracted  in  30-72 
per  cent.,  and  discharges  a  bloody  fluid  in  15"36  per 
cent.  The  glands  are  contaminated  in  23*07  per  cent. 
In  the  three  cases  in  which  that  point  is  noted,  the 
disease  had  lasted  in  two  for  twelve  years,  and  in 
one  for  twenty-four  months.  In  the  ten  in  which 
the  glands  were  normal,  one  had  existed  for  ten,  and 
another  for  foui^efen  years,  the  average  being  three 
years  and  a  half.  Of  the  five  cases  that  were  living 
without  recurrence,  in  not  a  case  was  there  antecedent 
glandular  or  other  complication,  while  in  the  two  that 
died  with  metastatic  deposits  death  was  preceded  by 
glandular  implication. 

The  skin  is  adherent  in  23*07  per  cent.,  and  it  also 
contains  distinct  nodules  in  one-third  of  these.  Ul- 
ceration is  met  with  in  15 "38  per  cent.  The  tumor  is 
fixed  to  the  chest,  and  the  pectoral  muscles  are  per- 
vaded by  tubers,  in  15*38  per  cent. ;  and  both  breasts 
are  involved  in  15*38  per  cent. 

Of  the  two  cases  that  ran  a  natural  course,  both  died 
at  the  end  of  twelve  years  from  the  first  observation 
of  the  disease,  and  in  both  the  glands  were  tainted. 
In  one  recorded  by  Doutrelepont,'  the  entire  skin  of 
the  chest  was  pervaded  by  nodules,  thereby  constitu- 
ting cancer  en  cuirasse,  and  secondary  deposits  were 

'  Lan^enhecKs  Archiv,  Bd.  xii,  p.  551. 


176  COLLOID   CARCINOMA. 

found  in  the  pleura  and  lungs.  In  the  second  case, 
section  disclosed  metastatic  tumors  in  the  pleura, 
lungs,  bronchial  glands,  mediastinum,  and  diaphragm. 

In  one  death  occurred  from  the  consequences  of 
the  operation.  There  was  no  section,  but  the  disease 
had  existed  for  ten  years. 

In  five  there  is  no  further  history  after  operation, 
but  the  tumor  had  existed,  on  an  average,  for  two 
years  and  a  half. 

In  five  cases  the  patients  were  still  alive  and  free 
from  recurrence ;  in  three,  respectively,  for  13,  19,  and 
20  months,  and  the  disease  had  existed,  on  an  aver- 
age, for  five  years  before  operation ;  and  in  two '  there 
was  no  recurrence  in  3  years,  and  in  5  years  and  10 
months,  and  the  disease  had  existed,  on  an  average, 
for  nine  months  befoi^e  surgical  intervention.  Hence 
these  cases  may  be  regarded  as  cured. 

From  these  facts  it  will  be  seen  that,  although  the 
disease  requires  twelve  years  to  run  its  course  when 
uninterrupted  by  operation,  it  is  impossible  to  calcu- 
late what  eifect  operation  has  on  prolonging  life. 
The  most  that  can  be  said  is  that,  in  the  cases  in 
which  the  histor}^  is  complete,  the  patients  were  still 
living  upward  of  thirty-one  months  after  operation, 
and  that  the  disease  had  existed  previous  to  opera- 
tion forty  months. 

The  only  tumor  for  which  colloid  cancer  is  liable 
to  be  mistaken  is  myxoma,  and  the  differences  be- 
tween them  are  now  and  then  so  slisrht  that  the  deter- 
mination  of  them  from  their  clinical  features,  it  'must 
be  confessed,  is  by  no  means  easy. 

'  F.  E.  Schulze,  3Iax  SchuUze's  Archiv,  Bd.  i,  p.  336,  and  Sattcrthwaitc, 
op.  ciL,  p.  98. 


CARCINOMA.  177 

Their  affinities  and  contrasts  are  as  follows : 
Myxoma  is  met  with  8  per  cent!  more  frequently 
before  the  age  of  forty,  and  17  per  cent,  less  fre- 
quently after  fifty,  although  the  average  age  of  occur- 
rence does  not  materially  differ  in  the  two  affections. 
Myxoma  is  soft  in  40  per  cent,  more  of  cases,  and 
it  grows  more  rapidly  and  attains  a  greater  volume 
than  colloid  carcinoma.  In  the  former  the  subcuta- 
neous veins  are  never  prominent,  and  the  nipple  is 
retracted,  and  the  axillary  glands  are  enlarged  less 
frequently,  respectively,  by  16*44  per  cent.,  and  8.79 
per  cent. ;  but  invasion  of  the  skin  and  ulceration  are 
more  common,  respectively,  by  34*07  per  cent,  and 
13*69  per  cent.,  although  it  is  not  attended  with 
deep  adhesions  or  extension  to  the  pectoral  muscles. 
While  reproduction  after  operation  is  not  met  with 
in  colloid  carcinoma,  it  occurs  in  33*33  per  cent,  of  all 
cases  of  myxoma;  but  metastatic  tumors  are  not  met 
with  in  the  latter.  The  average  duration  of  life  of 
those  living  after  operation  is  54  months  for  myxoma 
against  71  months  for  colloid  cancer.  Hence  the 
histoiy  of  colloid  carcinoma  shows  that  it  is  a  rela- 
tively benign  growth. 

AxEOPHYmG  SciREHUs. — Withering,  or  atrophy- 
ing, scirrhus  is  usually  stated  to  be  a  disease  of  more 
advanced  life,  and  to  pursue  a  milder  course  than  the 
other  forms  of  carcinoma,  as  regards  glandular  and 
visceral  participation;  and  these  assumed  attributes 
are  said  to  arise  from  its  tendency  to  result  in  a  nat- 
ural cure.  While  it  is  certainly  true  that  the  older 
portions  of  the  tumor  do  undergo  cicatricial  contrac- 
tion and  atrophy,  it  is  none  the  less  true  that,  so 
12 


178  ATROPEYIFG  SCIRRHUS. 

far  from  nature  effecting  a  cure,  tlie  surrounding  tis- 
sues are  simultaneously  being  invaded  to  a  far  greater 
extent  tlian  is  met  witli  in  any  otlier  variety  of  can- 
cer, and  tliat  local  reproduction  after  extirpation  is 
constant.  In  point  of  fact,  withering  scirrlius  evinces 
signs  of  local  and  general  extension  to  so  wonderful 
a  degree  that  post-mortem  inspection  has  never  failed 
to  disclose  visceral  deposits ;  and,  as  I  have  just  stated, 
recurrence  is  invariable.  The  recurrent  disease  is, 
moreover,  more  intense  than  in  any  other  cancer,  tak- 
ing place  in  three-fourths  of  all  instances  during  or 
soon  after  cicatrization,  and  showing  itself  in  the 
glands,  and  as  tubers  in  the  skin,  subcutaneous  con- 
nective tissue,  and  pectoral  muscles.  In  one  case,  in- 
deed, the  entire  course  of  the  disease  was  only  seven 
months,  and  two  operations  for  recuiTence,  the  sec- 
ond having  been  a  most  extensive  one,  were  practiced. 
In  one  case  of  death  from  operation,  secondary  de- 
posits Avere  found  in  the  liver,  and  the  disease  had 
existed  only  five  months  in  a  woman  of  fifty-five 
years.  In  still  another  example,  in  which  the  disease 
developed  at  the  forty-fourth  year,  on  death  mthout 
operation  in  one  year  metastases  were  found  in  the 
lungs,  pleura,  and  liver.  From  a  study  of  seventeen 
cases,  which  include  two  of  my  o\vn,  I  can  find  no- 
thing to  confirm  the  idea  that  the  course  of  the  dis- 
ease is  more  rapid  when  it  develops  early  than  late  in 
life. 

Although  patients  may  live  ^vith  the  disease  many 
years,  even  for  a  quarter  of  a  century,  they  none  the 
less  surely  die  from  its  effects,  and,  the  longer  it  lasts, 
the  more  liable  are  the  adjacent  tissues,  glands,  and 
the  viscera  to  extensive  infection.     Thus  I  have  re- 


CARCINOMA.  179 

corded  a  case/  tlie  structural  features  of  whicli  are 
represented  in  fig.  20,  in  wliich  tlie  tumor  first 
showed  itseK  at  the  age  of  forty-six  years,  and,  on 
death  seventeen  years  later,  the  skin  of  the  coitc- 
sponding  mammary  and  scapular  regions,  and  of  the 
opposite  breast,  and  at  the  base  of  the  xiphoid  carti- 
lage, was  pervaded  by  lenticular  nodules ;  the  axil- 
lary portions  of  the  pectoral  muscles  were  converted 
into  densely  hard  masses ;  the  glands  of  the  corre- 
sponding axilla  and  supraclavicular  fossa  and  of  the 
left  axilla  were  enlarged  and  indurated;  and  both 
lungs,  the  pleura,  the  bronchial  and  mediastinal 
glands,  and  left  half  of  the  diaphragm,  and  one  kid- 
ney, were  beset  with  metastatic  deposits.  In  a  second 
case,  the  external  features  of  which  are  shown  in  fig. 
29,  and  the  minute  appearances  of  which  are  depicted 
in  figs.  18  and  21,  I  recently  removed,  on  account  of 
excessive  suffering,  a  tumor  of  fourteen  years'  duration, 
which  had  commenced  at  the  age  of  thii'ty-one.  Not 
only  was  the  pectoral  fascia  itself  infiltrated,  but  the 
subjacent  muscle  was  so  extensively  occupied  by  nod- 
ules as  to  demand  the  removal  of  its  larger  portion. 
The  axillary  glands  formed  a  densely  hard  tumor, 
which  extended  up  under  the  clavicle,  and,  as  it  was 
intimately  attached  to  the  axillary  vessels  and  nerves, 
I  was  obliged  to  leave  a  portion  in  the  wound. 

Withering  scirrhus  occurs  as  early  as  29  and  as 
late  as  65  years,  the  average  being  47,  or  earlier  than 
the  other  varieties  of  carcinoma,  except  the  medul- 
lary ;  23'5  per  cent,  develop  before  the  fortieth  year, 
and  'TG'S  per  cent,  after  that  age,  of  which  more  than 
one-half  occur  after  the  age  of  fifty. 

'  Philadelphia  Medical  Times,  vol.  viii,  p.  84. 


180 


ATROPHYING  SCIRREUS. 


Its  consistence  is  densely  liard,  its  volume  is  ex- 
ceedingly small,  and  its  outline   is  nodular,  knotty, 


and  irregular. 


Tlie  subcutaneous  veins  are  never  enlarged ;  but 
tlie  nipple  is  always  retracted. 


Atrophying  Scirrhus  of  the  Eight  Mammary  Gland. 


The  lymphatic  glands  are  infected  in  52-94  per 
cent,  of  all  cases ;  and  their  implication  invariably  pre- 
cedes metastases. 

The  skin  is  adherent  in  58*82  per  cent. ;  contains 


CARCINOMA.  181 

nodules  in  17*64  per  cent. ;  and  is  ulcerated  in  41-17 
per  cent,  of  all  instances. 

The  tumor  is  fixed  to  tlie  pectoral  fascia,  and  in 
the  majority  of  cases  closely,  in  39-29  per  cent. ;  and 
nodules  are  disseminated  in  the  pectoral  muscles  in 
57-14  per  cent,  of  all  cases.  The  opposite  breast  is 
invaded  in  one  case  out  of  every  seventeen. 

Of  eight  eases  that  pursued  a  natural  course,  four 
were  living,  their  average  life  having  been  14  years 
and  9  months ;  and  four  were  dead,  theii*  average  life 
having  been  6  years  and  10  months.  In  two  of  these 
cases  post-mortem  examinations  were  made,  and  they 
disclosed  metastases  in  the  lungs,  pleura,  and  liver, 
in  one ;  and  in  various  organs,  as  I  have  indicated 
above,  in  a  case  of  my  own. 

Of  nine  cases  that  underwent  operation,  one  died 
of  its  consequences ;  the  total  duration  of  the  disease 
was  five  months,  and  secondary  tumors  were  found 
in  the  liver.  Three  died  with  recurrence,  and  their 
average  life  was  nineteen  months ;  one  was  still  living 
with  extensive  local  recurrence,  four  years  and  a  third 
having  elapsed  since  the  first  observation  of  the  dis- 
ease. Four  recovered ;  but  their  histories  end  mth 
that  statement,  and  their  average  life  was  four  years 
and  ten  months. 

Hence,  in  the  cases  in  which  the  histories  are  com- 
plete, recurrence  of  the  disease  was  invariable ;  and 
metastatic  tumors  were  found  in  every  case  in  which 
the  body  was  opened  after  death.  In  point  of  ma- 
lignity, therefore,  although  its  course  is  essentially 
chronic,  atrophying  scirrhus  is  the  most  pernicious  of 
the  tumors  of  the  breast. 

With  the  view  of   comparing  the  several  char- 


182   AFFINITIES  AND   CONTRASTS  OF  VARIETIES. 

acteristics  of  tlie  varieties  of  carcinoma,  I  Lave  drawn 
up  tlie  principal  points  in  the  Mstory  of  their  lives, 
in  the  following  table,  which  will  be  of  ser\ace  in 
determining  their  diagnosis,  prognosis,  and  fitness  for 
operation.  Under  fibrous  are  included  ordinary  and 
simple  sciiThus,  as  they  pursue  precisely  the  same 
course,  as  well  as  a  few  cases  of  other  fonns  of  car- 
cinoma; but  the  latter  constitute  so  small  a  propor- 
tion of  the  entire  number  that  the  percentages  would 
scarcely  be  changed  if  it  were  possible  to  separate 
them.  As  the  column  contains  the  results  of  my 
analysis  of  the  tables  of  Winiwarter,  Oldekop,  and 
Henry,  and  of  my  own  one  hundi-ed  cases,  and  cor- 
responds to  my  general  description  of  the  disease, 
those  of  my  readers  Avho  desire  to  be  more  exact  may 
change  the  heading  to  carcinoma  in  general.  The 
metastases  are  based  upon  post-mortem  inspection 
alone,  and  the  cures  upon  fi-eedom  from  local  or  gen- 
eral recurrence  for  tliree  years  after  the  last  operation. 


Average  ajre 

Consistence 

Veins  prominent 

Nipple  retracted 

"      dischariring 

Glands  infected 

Skin  adherent 

Nodules  in  skin 

Tllceration 

Fixation  to  chest 

Nodules  in  pectoral  muscle. 

Both  breasts 

Av.  life  without  operation. 
"      '•    with  " 

Local  reproduction 

Metastatic  deposits 

Cured 


Fibrous. 

Medullary. 

Colloid. 

Atrophj-fngf. 

48  vears. 

50  vears. 

45  vears 

47  years. 

Never  soft. 

Soft  in  66  p.  c. 

Partly  soft  in  7 -C9  p.  c. 

Never  sofL 

208  p.  c. 

9-0!)  p.  c. 

23-07  p.  c. 

0       p.  c 

52          " 

33-33    " 

30-72    " 

100 

9 

0 

15-38    " 

0 

64-23    " 

59-02    " 

28-07    " 

52-94    "■ 

84-54    " 

52-92    " 

23-07    " 

58-82    " 

10-61    " 

5-83    " 

7-69    " 

17-64    " 

23-77    " 

18-18    •' 

15-33    " 

41-17    " 

21 -5S    " 

29-41     » 

15-33    " 

85-29    " 

7-06    " 

11-76    " 

15-83    " 

57-14    " 

3-65    " 

9-09     " 

15-38    " 

5-88    " 

27 -1  mos. 

8  mos. 

144  mos. 

82  mos. 

39 

Ifii  -' 

? 

18    " 

80-97  p.  c. 

81-81  p.  c. 

0       p.  c. 

100  p.  c 

60 

100 

100 

100    " 

9-05    " 

11-11   " 

is-is   •' 

0    " 

CHAPTER   X. 

CYSTS. 

A  CYST  may  be  defined  to  be  a  sac  filled  with 
more  or  less  fluid  contents.  When  the  accumulation 
takes  place  in  the  secreting  structures  of  the  mamma, 
the  connective  tissue  membrane  which  forms  the  wall 
of  the  cavity  is  lined  by  epithelium,  whereas  it  is 
merely  a  fibrous  capsule  when  it  is  a  new  formation. 

The  usual  nomenclature  of  cysts  is  entirely  arti- 
ficial, as  it  is  based  upon  the  nature  of  their  contents, 
a  classification,  it  need  scarcely  be  said,  which  affords 
no  clue  to  the  mode  of  their  origin.  In  accordance 
with  their  derivation  they  may  be  separated  into  re- 
tention cysts  and  cysts  of  new  growth,  the  latter 
including  membranes  which  limit  hydatids,  and  pos- 
sibly a  fibrinous  coagulum,  as  in  the  examples  re- 
corded by  Schuh  '  and  Gay."  As  I  have  been  unable 
to  refer  to  the  original  paper  in  the  one,  and  as  the 
description  is  very  defective  in  the  second  case,  I  am, 
however,  in  doubt  whether  the  blood  was  originally 
contained  in  a  dilated  duct,  or  extravasated  into  the 
periglandular  connective  tissue,  and  subsequently  en- 
closed in  a  fibrous  wall,  although  the  foimer  origin  is 
the  more  plausible.     In  addition  to  these,  Albers '  has 

'  Klebs,  Hdbch.  der  Path.  Anat ,  p.  1197. 
*  B>ston  Med.  and  Surg.  Jour.,  1878,  p.  90. 
3  Erliiuterungen,  Bd.  iii,  p.  589. 


184  BETENTION  CYSTS. 

described  a  dermoid  cyst  containing  liair  and  seba- 
ceous matter,  and  supposed  sebaceous  cysts  liave  been 
removed  by  Gerdy/  Lawrence/  and  Dieffenbacli ; ' 
but  they  were  probably  nothing  more  than  inspis- 
sated lacteal  cysts,  and  need  not  detain  us. 

1.  Retention  Cysts. 

When  from  any  cause  whatever  the  lacteal  ducts 
are  obstructed,  constricted,  or  obliterated,  the  glan- 
dular apparatus  behind  the  lesion  is  converted  into 
a  sac  throuo;h  retention  and  accumulation  of  its  secre- 
tion.  As  the  surrounding  stroma  is  not  concerned 
in  their  formation,  these  cysts  are  to  be  carefully 
distinguished  from  the  softening  cysts  which  are  of 
not  infrequent  occurrence  in  the  neoplasms  prop- 
erly so  called,  and  from  the  duct  cysts  which  are  so 
commonly  found  in  connection  with  fibroma,  sarcoma, 
and  myxoma.  The  former  constitute  cystoid,  and  the 
latter  cystic  tumors,  while  the  affection  under  con- 
sideration is  known  simply  as  cyst  of  the  mamma. 

For  convenience  of  description  retention  cysts 
may  be  divided  into  the  simple,  which  comprise  the 
serous,  mucous,  sero-sanguinolent,  and  hematic;  and 
the  lacteal,  which  include  the  oil  and  butyroid  cysts 
of  various  authors.  Their  occurrence  is  so  rare  that, 
as  I  have  already  pointed  out  at  page  9,  they  con- 
stitute less  than  2  per  cent,  of  all  tumors  of  the 
breast. 

A.  Simple  Cysts.  —  Retention  and  accumulation 
of  the  secretion  and  consequent  ecstasia  of  the  lacteal 

'  Velpeau,  op.  cit.,  Syd.  ed  ,  p.  247. 

«  Ibid.,  p.  248. 

^  Lebert,  Bull,  de  la  Soc.  Anat.^  1852,  p.  42. 


CYSTS.  185 

glands  and  their  ducts  may  arise  from  malformation 
of  the  nipple ;  from  inflammation  due  to  injury  or 
puerperal  mastitis ;  from  the  presence  of  small  vege- 
tations in  the  ducts ; '  from  cicatricial  contraction  of 
the  fibrous  stroma  of  the  mamma;  and,  it  may  be, 
from  errors  of  development  during  the  unfolding  of 
the  gland  after  the  establishment  of  the  menses, 
through  which,  as  Meckel  suggested,  the  lobules  form 
more  rapidly  than  the  ducts.  In  accordance  with 
the  period  of  their  development  they  may  be  sep- 
arated into  involution  and  evolution  cysts,  the  former 
appearing  after,  and  the  latter  before,  the  menopause. 
a.  Involution  cysts,  or  those  which  occur  in  the 
atrophying  or  obsolescent  gland,  are  directly  trace- 
able to  dilatation  principally  of  the  acini,  as  may 
be  demonstrated  by  minute  examinations  of  sections 
made  from  their  immediate  vicinity.  In  a  careful 
study  of  two  specimens,  I  found  that  the  sclerosed 
and  contracting  fibrous  tissue  not  only  strictures  the 
ducts,  but  also  induces  irritative  hyperplasia  of  the 
epithelium,  as  indicated  by  its  proliferation  and  accu- 
mulation in  the  acini.  The  cells  then  undergo  re- 
gressive changes,  through  which  they  are  converted 
into  a  lactescent  or  mucoid  fluid,  so  that  a  single 
acinus  appears  as  an  enlarged  round  or  ovoid  cavity, 
surrounded  by  its  proper  membrane,  which  is  lined 
by  a  single  layer  of  cuboid  or  cylindrical  cells.  As  a 
rule,  all  the  acini  of  a  lobule  participate  in  these 
alterations ;  and  the  cyst  increases  in  size  by  the 
fusion  or  coalescence  of  the  contiguous  acini,  as  is 
frequently  shown  by  the  projection  of  the  remains  of 
the  septa,  in  the  form  of  irregular  connective  tissue 

'  Rogeau,  Bull,  de  la  Soc.  Anat.,  t.  xlix,  p.  108. 


186  INVOLUTION  CYSTS. 

papillae,  into  tlie  common  cavity.  These  processes 
sometimes  persist  and  enlarge,  so  that  tlie  inner  layer 
of  the  cyst  is  here  and  there  studded  with  minute, 
soft,  vascular  excrescences,  which  impart  to  it  a  vil- 
lous appearance,  discernible  by  the  naked  eye.  They 
do  not,  however,  arise  from  the  periacinous  stroma, 
whereby  they  are  distinguished  from  the  large  intra- 
cystic  growths  of  the  connective  tissue  neoplasms. 
With  their  further  enlargement  the  walls  of  the  cyst 
become  thickened  through  hyperplasia  of  the  adven- 
titia  of  the  membraua  propria,  and  their  epithelial 
lining  assumes  the  characters  of  the  pavement  variety. 

In  the  breasts  which  I  have  examined  the  oriscinal 
changes  were,  for  the  most  part,  confined  to  the  acini, 
but  in  sections  from  the  same  specimens  the  ducts 
were  also  seen  to  participate  in  the  process.  In  some 
cuts  the  transfoimed  acini  communicated  with  dilated 
tubules ;  while  in  others,  and  in  the  majority,  the 
acinous  alterations  appeared  to  have  been  induced  by 
obliteration  of  the  ducts  in  their  immediate  vicinity. 
Hence,  I  refer  the  fonnation  of  involution  cysts  pri- 
marily to  the  acini,  although  not  to  the  entire  exclu- 
sion of  the  ducts. 

The  cysts  which  occur  after  the  menopause,  or  at 
the  average  age  of  fifty-four  years,  are  usually  seated 
at  the  posterior  surface  and  the  periphery  of  the 
breast,  vary  in  size  from  a  pea  to  a  cheriy,  and  contain 
greenish  fluid.  In  the  majority  of  instances  they  are 
discovered  only  after  the  removal  of  the  organ  under 
the  supposition  that  the  disease  was  carcinoma. 

In  eio;ht  instances  in  which  the  affection  had  at- 
tained  sufficient  dimensions  to  demand  surgical  inter- 
ference, the  cyst  was  single  in  five  and  multiple  in 


CYSTS.  187 

tliree.  In  tlie  former  the  sac  varies  from  the  volume 
of  a  hen's  egg  to  that  of  a  double  fist,  and  its  contents 
are  always  discolored.  Its  rate  of  gi^owth  is  variable. 
It  sometimes  increases  comparatively  quickly,  as  did 
one  recorded  by  Richelot,'  which  in  less  than  three 
years  acquired  a  bulk  greater  than  that  of  two  fists. 
On  the  other  hand,  it  requires  many  years  to  attain 
the  size  of  an  egg,  so  that  an  average  rate  of  growth 
cannot  be  assigned  to  it.  When  the  cysts  are  mul- 
tiple, it  is  usually  found  that  one  has  rather  large 
dimensions,  and  that  it  is  surrounded  by  others  which 
were  not  sufiiciently  developed  to  be  detected.  In  a 
case  reported  by  Lawson,"  the  disease,  which  was  of 
two  vears'  duration,  and  had  be2:un  at  the  ag^e  of 
fifty-eight  years,  presented  itself  as  two  large  sacs 
which  had  replaced  the  entire  gland,  and  rendered 
it  so  bulky  and  heavy  as  to  require  support  in  a 
sling. 

The  diagnosis  of  multiple  cysts  is  not  easy,  since 
the  age  of  the  patient,  the  hard,  irregular,  and  knot- 
ted feel  of  the  breast,  and,  it  may  be,  the  presence 
of  an  enlarged  gland  in  the  axilla,  as  in  an  example 
witnessed  by  Paget,'  suggest  the  idea  of  carcinoma. 
When,  on  the  other  hand,  the  cyst  is  single  or  double, 
and  of  considerable  volume,  its  nodulated  or  slightly 
lobulated  outline,  the  thinned  state  and  violaceous  or 
dusky-red  tint  of  the  skin,  the  fluctuation,  and  prob- 
ably a  discharge  from  the  nipple,  are  signs  that  can- 
not be  mistaken.  In  either  event,  the  prognosis  is 
favorable,  as  it  is  in  all  the  cystic  formations  of  the 
mamma. 

'  Des  Tumeurs  Kijstiques  de  la  Mamelle,  Paris,  187S,  p.  113. 

'  Trajis.  Path.  Soc.  London^  vol.  xxi,  p.  354.  ^  Op.  cit.,  p.  408. 


188  EVOLUTION'  CYSTS. 

13.  Evolution  cysts,  or  those  wliicli  form  during 
tlie  period  of  tlie  functional  activity  of  tlie  breast,  are 
usually  due  to  dilatation  of  tlie  lacteal  sinuses  and 
larger  ducts,  since  only  about  one-fourtli  originate  in 
the  same  way  as  do  the  cysts  of  the  senile  gland. 
Of  22  examples  that  I  have  analyzed,  four  of  which 
came  under  my  personal  observation,  the  tumor  was 
single  in  17  and  multiple  in  5.  The  walls,  as  a 
rule,  are  thin  and  vascular,  while  in  rare  cases  they 
are  calcified.'  The  contents,  originally  of  a  lactes- 
cent nature,  vaiy  greatly  in  their  appearances.  In 
5  per  cent,  of  all  cases  they  are  greasy  and  oleagi- 
nous ;  in  25  j)er  cent,  they  are  serous;  in  25  per  cent, 
they  are  of  a  reddish  hue  or  sero-sanguinolent ;  while 
in  the  remainder  they  are  of  a  green,  brown,  greenish- 
brown,  black,  dark-red,  or  yellow  tint  from  altered 
hsematin,  and  frequently  contain  plates  of  choles- 
terine.  Although,  when  solitary,  they  are  usually  of 
the  size  of  a  walnut,  they  may  constitute  globular  or 
ovoid  tumors  as  large  as  a  goose's  egg,  a  fist,  or,  as  in 
the  case  of  Marini,"  may  contain  nine  pounds  of  fluid. 
When  multiple,  hundreds  may  be  scattered  through- 
out the  gland,  their  volume  varying  from  that  of  a 
hemp-seed  to  that  of  a  pigeon's  egg.  In  this  event, 
their  walls  are  liable  to  be  thick. 

Single  cysts  are  most  common  in  the  central  area 
of  the  breast,  and  are  decidedly  frequent  near  the 
areola,  from  implication  of  the  lacteal  sinuses.  They 
may,  however,  originate  in  the  accessory  glands  which 
lie  in  the  connective  tissue  immediately  beneath  the 
areola,  and  which  Dr.  Sinety'  has  demonstrated  to 

'  Velpeau,  Diseases  of  the  Breast,  Sydenham  Soc.  ed.,  p.  272. 

'  Gazette  des  Hopitaux,  1838,  p.  282.       ^  ^„;;.  ^^  i^  g^^^  A:iiat.,  t.  lii,  p.  460. 


CYSTS.  189 

exist,  to  the  average  number  of  four,  in  every  fourteen 
out  of  fifteen  women.  A  case  described  by  Velpeau/ 
in  wliich  a  young  girl  could  express  a  reddish  fluid 
through  a  small  opening  two  lines  below  the  nipple, 
doubtless  conies  under  this  category.  Multiple  cysts, 
on  the  other  hand,  usually  develop  at  the  posterior 
surface  of  the  mamma  and  at  its  peripheiy. 

The  disease  is  most  frequent  in  comparatively 
young  married  and  prolific  women.  Thus,  of  the  22 
cases,  the  age  of  11  was  from  thirty  to  forty  years,  of 
5  from  twenty-one  to  twenty-eight,  of  1  fifteen,  and 
of  5  from  forty-two  to  forty -five,  or  of  the  thii^ty-f  ourth 
year  on  an  average ;  while  17  were  mamed  and  5 
were  single.  Five  examples  were  directly  attributa- 
ble to  injury ;  but  the  exciting  cause  was  inapprecia- 
ble in  the  remainder. 

The  outline  of  evolution  cysts  is  usually  smooth, 
nodulation  or  bosselation  being  rare  even  when  the 
sac  is  large.  Their  volume,  as  a  rule,  hardly  exceeds 
that  of  a  walnut,  that  of  a  filbert  or  a  pigeon's  egg 
being  attained  in  a  year,  although  in  one  of  my  cases 
the  size  of  an  orange  was  reached  in  that  time.  Bill- 
roth '  records  one  as  large  as  a  goose's  egg  in  five 
years ;  and  Richelot '  one  of  the  bulk  of  the  fist  in  fif- 
teen years ;  while  in  the  case  of  Marini  *  the  cyst  con- 
tained nine  pints  of  a  serous  fluid  in  the  short  space 
of  three  months.  On  the  whole,  it  may  be  said  of 
these  cysts  that  their  volume  is  moderate,  and  that 
their  increase  is  slow. 

The  consistence  of  evolution  cysts  is  usually  firm 
and  elastic,  fluctuation  being  distinct  only  in  excep- 

'  Op.  cit,  p.  251.  2  Chir.  Klinik,  Wien,  lS69-"70,  p.  143. 

'  Op.  cit.,  p.  112.  *  A7ite. 


190  EVOLUTION  CYSTS. 

tional  instances.  In  one  example  out  of  every  tliree 
and  two-tliirds  there  is  a  discliarge  from  the  nipple, 
but  it  is  spontaneous  in  only  one-half  of  these.  The 
mammilla  itself  is  defonned  in  one  case  out  of  every 
seven  and  one-thii'd,  being  buried,  through  the  pro- 
jection of  the  sac  beyond  its  level,  and  preventing 
suckling.  There  are  no  adhesions  to  the  skin  or  to 
the  chest ;  the  subcutaneous  veins  vrere  prominent  in 
one  example  of  a  large  inflamed  solitary  cyst ;  there  is 
slight  pain  in  one  case  out  of  every  seven  and  one- 
third  ;  and  the  partially  translucent  cyst  may  have  a 
bluish  tint  in  4*5  per  cent,  of  all  instances. 

They  are  not  very  liable  to  inflammation  or  ulcer- 
ation. In  the  case  of  Richelot,  the  sac  suppurated, 
and  ulceration  and  gangrene  of  the  skin  ensued ;  while 
in  one  instance  of  multiple  cysts,  recorded  by  Sir 
Astley  Cooper,'  several  ulcerated,  but  subsequently 
healed.  In  both  of  these  there  was  an  enlarged  gland 
in  the  axilla,  a  condition  which  was  not  met  mth  in 
the  remaining  cases. 

The  diagnosis  of  a  small  cyst  is  impossible  with- 
out a  resort  to  the  exploring  needle,  since  its  fii'm  con- 
sistence, mobility,  and  painless  and  chronic  course  ren- 
der it  veiy  liable  to  be  confounded  ^vith  a  small  solid 
neoplasm.  A  growth  which  presents  these  features, 
and  which  is  seated  near  the  nipple  of  a  mamed 
woman  between  twenty-five  and  forty  years  of  age, 
and  which  is  preceded  by,  or  attended  with,  a  dis- 
charge from  the  nipple,  may  reasonably  be  suspected 
to  be  an  evolution  cyst,  while  distinct  fluctuation 
and  a  bluish  tint  go  far  to  clear  up  the  true  na- 
ture of  the  case.     When  multiple   the  breast  may 

*  Op.  cit.,  Case  VI  of  hydatid  tumors.     , 


CYSTS.  191 

present  a  bossed  appearance,  but  tlie  cliaracters  of 
tlie  individual  bosses  or  tubers  are  merely  those  of  a 
single  cyst. 

B.  Lacteal  Cysts. — Galactoceles,  or  cysts  contain- 
ing either  pure  or  altered  milk,  are  even  more  rare 
than  simple  cysts,  and  are  due  almost  exclusively  to 
dilatation  of  the  sinuses  and  larger  ducts,  the  majority 
being  found  in  the  immediate  vicinity  of  the  nipple 
and  areola.  In  accordance  with  their  consistence  they 
are  divided  into  liquid  and  solid  galactoceles,  the  for- 
mer predominating.  Of  seventeen  cases  which  I  have 
collated,  inclusive  of  two  under  my  own  care,  the 
contents  were  pure  milk  in  seven ;  of  the  nature  of 
cream  in  two ;  oil  in  one ;  of  a  partly  curdy  material 
and  partly  fluid  character  in  one ;  of  a  semisolid,  dry, 
grayish-white  curd  or  caseous  matter,  which  is  com- 
posed of  broken-down  epithelial  cells,  globules  of  oil, 
and  acicular  crystals  of  palmitine  and  stearine,  or  a 
mixture  formerly  called  margarine,  in  five ;  and  of  the 
nature  of  butter,  whence  the  term  butyroid  cyst,  in 
one.  These  variations  in  the  character  of  the  con- 
tents are  dependent  upon  the  chemical  and  mechani- 
cal changes  which  the  milk  undergoes,  the  inspissation 
becoming  more  marked  as  that  fluid  parts  with  its 
watery  constituent,  and  as  the  albuminous  elements 
predominate.  Calcification  of  the  caseous  mass,  which 
has  been  observed  in  animals,  and  which  is  said  by 
some  authors  to  occur  in  the  female  breast,  appears 
to  be  rather  a  tradition  than  a  fact  founded  upon  ac- 
tual observation. 

Lacteal  cysts  are  almost  invariably  solitary,  the 
only  exception  to  the  rule  of  which  I  have  any  kno^vl- 


192  LACTEAL   CYSTS. 

edge  being  a  case  recorded  by  Forget.'  In  tliis  case, 
in  addition  to  tlie  principal  sac,  wliicli  was  of  the  vol- 
ume of  a  double  fist,  there  were  two  others  of  the 
size  respectively  of  a  pigeon's  egg  and  a  hazel-nut. 
These  cysts  are  not  liable  to  inflammation,  although 
in  the  instance  just  mentioned  the  wall  of  the  largest 
was  the  seat  of  two  ulcers,  the  bases  of  which  were 
formed  by  the  softened  and  slightly  suppurating  mam- 
mary tissue.  Sir  Astley  Cooper "  states  that  ulcera- 
tion, A\dth  escape  of  its  contents,  sometimes  follows 
excessive  distention  of  the  sac ;  but  the  cases  which  I 
have  examined  do  not  confiim  this  assertion. 

Galactoceles  are  generally  observed  during  lacta- 
tion. Thus,  of  fifteen  examples  in  which  the  date  of 
appearance  is  noted,  twelve  occurred  at  a  period  which 
varied  from  ten  days  to  seven  months  after  partui'i- 
tion,  and  usually  within  three  months ;  one  *  developed 
sixteen  months  before  childbirth,  and  increased  most 
rapidly  after  weaning ;  one  appeared  during  preg- 
nancy ;  while,  in  a  remarkable  instance  recorded  by 
Bouchacourt,*  an  enormous  cyst,  filled  ^^^th  pure 
milk,  formed  in  a  woman  fifty-one  years  of  age 
twenty-four  years  after  her  last  accouchement.  In 
two  examples  the  disease  was  attributed  to  a  blow, 
and  in  at  least  one  there  was  antecedent  mastitis. 

The  outline  of  a  milk  cyst  is  globular  or  ovoid,  and 
not  infrequently  somewhat  nodulated,  while  its  vol- 
ume and  rate  of  increase  depend  upon  the  nature  of 
its  contents.  Thus,  when  the  contents  are  fluid  it  may 
apj)ear  rapidly  and  acquii'e  the  capacity  of  two,  six, 

'  Bull.  Gen.  de  TJurapeut.,  t.  xxvii,  p.  359. 

*  Diseases  of  the  Breast^  Phila.,  1845,  p.  19. 

*  W.  F.  Atlee,  Amer.  Jour.  Med.  Sciences,  April,  1874,  p.  419. 

*  Richelot,  op.  cit.,  p.  18. 


CYSTS.  193 

and  even  ten  pints  in  a  sliort  time,  as  in  tlie  cele- 
brated case  of  Scarpa.'  In  this  case  tlie  breast  began 
to  enlarge  ten  days  after  parturition,  and  in  less  tlian 
two  months  measured  thirty-four  inches  in  circum- 
ference and  rested  upon  the  thigh  when  the  patient 
was  seated.  On  the  other  hand,  when  the  accumula- 
tion is  slow,  the  increase  is  so  gradual  that  the  sac 
may  contain  only  ten  ounces  in  thirteen  years,  as  in 
an  example  recorded  by  Bii'kett.*  When  the  contents 
are  converted  into  a  cheesy  mass,  the  size  and  growth 
vary  from  the  dimensions  of  a  pigeon's  q^q^  in  seven 
months  to  those  of  a  child's  fist  in  three  years. 

During  its  entire  course  a  galactocele  is  unattend- 
ed with  pain  or  tenderness;  the  skin  is  not  discol- 
ored ;  the  nipple  is  natural,  except  in  rare  cases  in 
which  the  swelling  protrudes  beyond  its  level,  and 
interferes  'with  suckling ;  the  axillary  glands  are  not 
enlarged ;  there  are  no  adhesions ;  and  the  general 
health  does  not  suffer. 

A  large,  solitary,  pendulous,  painless,  soft,  and  fluc- 
tuating tumor,  with  prominence  of  the  subcutaneous 
veins,  which  formed  suddenly  during  lactation,  may 
safely  be  pronounced  to  be  a  cyst  containing  milk ;  and 
the  diagnosis  is  confirmed  if,  as  occasionally  happens,  a 
few  drops  of  that  fluid  can  be  made  to  escape  from 
the  nipple.  When  of  moderate  volume,  a  liquid 
galactocele  will  usually  be  found  to  increase  in  size 
at  each  successive  parturition,  to  become  tense  during 
suckling,  and  to  decrease  with  the  cessation  of  lactation. 
Despite  these  changes  in  volume,  it,  however,  continues 
to  grow  slowly,  and  is  the  seat  of  fluctuation. 

1  Boycr,  Ilaladics   Chirurgicales,  Jst  ed.,  t.  vii,  p.  217,  and  Forget,  loc.  cit., 
p.  356. 

*  Holmes's  System  of  Surgery,  2d  ed.,  Tol.  r,  p.  264. 
13 


194  HYDATID   CYSTS. 

When,  on  the  other  hand,  the  contents  are  of  a 
semisolid  or  cheesy  natui'e,  the  distinction  between  a 
lacteal  cyst  and  a  small  fibroma  is  scarcely  apparent. 
Thus,  in  a  lady  twenty-four  years  of  age,  whom  I 
recently  saw,  there  was  a  round,  slightly  nodulated, 
firm,  and  painless  tumor  just  internal  to  and  above 
the  areola,  which  rolled  under  the  finger,  was  of  the 
volume  of  a  hickory -nut,  and  was  of  sixteen  months' 
duration.  As  it  developed  two  weeks  after  parturi- 
tion, I  inclined  to  the  opinion  that  it  was  a  solid 
galactocele ;  but  I  was  not  certain  as  to  its  time  na- 
ture until  an  exploratory  incision  gave  vent  to  its 
curdy  contents.  In  such  cases  the  swelling  is  ob- 
served, soon  after  its  commencement,  to  fluctuate; 
but  it  gradually  becomes  solid,  and  frequently  dimin- 
ishes in  size,  and  may  even  retain  the  impression  of 
the  finger. 

Upon  the  whole,  in  the  absence  of  exploratory- 
puncture,  the  development  of  a  swelling,  without 
signs  of  inflammation,  during  lactation,  affords  pre- 
sumptive evidence  of  a  milk  cyst. 

2.  Hydatid  Cysts. 
When  the  embryo  of  the  taenia  echinococcus  finds 
its  way  into  the  stroma  of  the  mamma,  it  is  trans- 
formed into  a  vesicular  worm,  and  is  soon  encapsuled 
by  a  fibrous  membrane  of  new  formation,  in  which  it 
grows  and  multiplies  until  it  occasions  a  tumor  which 
may  attain  the  volume  of  a  fist.  It  is  the  most  un- 
common of  all  the  cysts  of  the  breast,  as  is  shown  by 
the  fact  that,  up  to  1874,  Haussmann*  of  Berlin  had 
been  able  to  collect  only  sixteen  examples,  to  which 

*  Die  Parasiten  der  BrustdriXse,  Berlin,  IS'Ti. 


CYSTS.  195 

may  be  added  two  cases  recorded,  respectively,  by 
Lauenstein'  of  Gottingen,  and  Landau'  of  Breslau. 
In  the  latter  tlie  sac  communicated,  by  an  opening 
three  centimetres  square  through  the  ribs  and  inter- 
costal muscles,  either  with  the  cavity  of  the  chest  or 
the  abdomen;  but  it  was  impossible  to  determine 
whether  it  was  connected  with  the  pleura,  the  dia- 
phragm, or  the  liver.  In  none  of  the  remaining  seven- 
teen cases  did  the  parasites  reach  their  destination  by 
ulceration  through  the  wall  of  the  chest,  but  they  en- 
tered it  through  the  usual  channel  of  the  circulation. 

In  the  majority  of  instances  there  is  a  single  cyst 
with  scolices  adhering  to  its  inner  wall  or  germinal 
membrane,  or  floating  in  its  clear  non-albuminous 
fluid  ;  while  in  the  others  there  is  a  parent  cyst  con- 
taining from  one  to  four,  but  rarely  more,  smaller 
vesicles,  the  size  of  the  former  varying  between  that 
of  an  apple  and  that  of  a  man's  fist.  The  limiting 
capsule  is  composed  of  vascular  connective  tissue,  and 
may  reach  the  thickness  of  two-fifths  of  an  inch. 

Hydatid  cysts  occur  as  early  as  the  twenty-sec- 
ond and  as  late  as  the  fifty-sixth  year.  Of  11  cases 
in  which  the  age  is  noted,  6  first  appeared  between 
20  and  30  years  ;  2  between  30  and  40  years ;  2  be- 
tween 40  and  50  years ;  and  1  after  the  age  of  50. 
Their  growth  is  extremely  slow,  although  it  is  very 
variable.  Thus,  they  may  attain  the  size  of  a  filbert 
in  eleven  months,  of  a  small  ^gg  in  two  years,  of  an 
orange  or  a  cocoa-nut  in  five  years,  of  a  pigeon's  egg 
in  six  years,  or  of  an  apple  in  eight  years,  so  that, 
while  an  average  rate  of  increase  cannot  be  assigned 

'  Ueher  der  Vorkommen  von  Echinococcus  in  der  Mamma.     Inaug.  Dissert., 
Gottingen,  1874. 

*    Archiv  fier  Gyncckologie^  Bd.  viii,  1875,  p.  350. 


196  HYDATID   CYSTS. 

to  them,  the  endogenous  hydatid  may  be  said  to 
be  of  slower  growth,  although  it  finally  acquires  a 
larger  volume,  than  the  single  cyst.  Their  increase  is 
materially  hastened  by  trauma,  and  in  one  instance 
appeared  to  advance  during  lactation. 

From  the  foui^teen  cases  which  are  available  for 
writing  the  life  history  of  these  tumors,  it  appears 
that  they  grow  slowly,  attain  moderate  size,  are  pain- 
less, of  a  round  and  smooth  outline,  of  a  firm,  or  firm 
and  elastic,  consistence,  mobile  under  the  skin,  not 
attached  to  the  chest,  seated  at  the  upper  and  outer 
part  of  the  breast  and  never  in  the  immediate  vicin- 
ity of  the  nipple,  free  from  changes  in  the  skin,  veins, 
and  lymphatic  glands,  little  liable  to  inflammation, 
and  do  not  impair  the  general  health. 

Deviations  from  this  general  course  were  indicated 
by  pain  in  two  instances ;  by  slight  tenderness  on 
manipulation  in  five  ;  by  a  nodulated  outline  in  two  ; 
by  fluctuation  in  five ;  by  attachment  to  the  skin  in 
four ;  by  irritative  hyperplasia  of  the  axillaiy  glands 
in  two  ;  and  by  inflammation,  with  ulceration  and 
the  escape  of  purulent  fluid,  which  had  accumulated 
between  the  parasite  and  the  enclosing  cyst  as  a  re- 
sult of  irritation,  in  three. 

While  the  prognosis  is  highly  favorable,  the  diag- 
nosis is  most  obscure,  the  discrimination  between  it 
and  a  simple  cyst  being  impossible,  but  being  easy 
when  compared  with  a  lacteal  cyst  which  appears 
during  lactation  and  is  usually  prominent  in  the  \dcin- 
ity  of  the  nipple.  In  two  cases  it  was  thought  to  be 
carcinoma ;  and  it  is  also  liable  to  be  confounded  mth 
other  neoplasms,  unless  exploratoiy  puncture  be  re- 
sorted to. 


CHAPTER  XI. 

TEE  DIAGNOSIS  OF  TUMORS  OF  THE  MAMMARY  GLAND. 

Iisr  the  formation  of  a  correct  diagnosis  of  mam- 
mary tumors  it  is  of  the  last  importance  that  both 
breasts  be  fully  exposed,  and  that  the  patient  be 
placed  in  the  recumbent  posture.  With  regard  to 
the  fii'^t  point  little  need  be  said,  as  a  comparison  of 
both  glands  frequently  serves  to  clear  up  features 
which  were  obscure  when  the  examination  was  con- 
fined to  one  alone.  In  many  women  who  have  borne 
children,  and  the  more  especially  should  the  breasts 
be  lax,  if,  as  too  commonly  occurs,  the  organ  be  ex- 
plored when  it  is  partially  confined  by  the  corset,  and 
it  be  seized  between  the  thumb  and  fingers  when  the 
patient  is  seated,  an  enlarged  or  apparently  enlarged 
lobe  may  be  felt,  which  conveys  the  impression  of  a 
distinct  tumor.  If,  however,  the  patient  be  recum- 
bent, and  the  gland  be  permitted  to  rest  in  its  normal 
position,  gentle  pressure  with  the  fingers  backward 
toward  the  chest  will  show  that  the  supposed  neo- 
plasm has  disappeared  ;  while,  if  one  really  exists,  it 
will  not  only  not  elude  this  mode  of  manipulation, 
but  be  rendered  more  prominent.  The  presence  of  a 
new  growth  having  been  determined,  the  first  desire 
of  the  surgeon  is  to  ascertain  whether  it  be  of  a  car- 
cinomatous or  of  a  non-carcinomatous  nature.  With 
the  view  of  facilitating  this  step  of  the  inquiiy,  the 


198  TUMORS  OF  THE  MAMMARY  GLAND. 

affinities  and  contrasts  of  tliese  two  great  clinical 
divisions  are  arranged  in  the  subjoined  tabular  form, 
and  are  based  upon  a  study  of  their  antecedents,  and 
of  the  prominent  points  in  their  general  pathology. 
The  non-carcinomatous  neoplasms  include  fibroma, 
sarcoma,  myxoma,  and  adenoma. 

Caeoinomatous  Tumoes/  Non-Caecinomatotts  Tumoes." 

Age  of  Development. 
Appear,  on  an  average,  at  the  Appear,  on  an  average,  at  the 

forty-eighth  year.  Y7'26  per  cent,  thirty-third  year.  30-37  per  cent, 
develop  after  the  age  of  forty,  and  develop  after  the  age  of  forty ; 
never  before  the  twentieth  year.  15"15  per  cent,  before  the  twen- 
In  impubic  girls  the  idea  of  cancer  tieth  year;  and  5'18  per  cent,  be- 
may  be  discarded.  fore  the  establishment  of  menstru- 

ation. 

Social  Condition. 

88 "22  per  cent,  of  the  patients  61  per  cent,  were  or  had  been 

were   or  had   been  married,  and  married  when  the  tumor  was  first 

11  "77  per  cent,  were   single.    Of  observed,  and  38  per  cent,  were 

the   former,    83-91   per  cent,  had  single.    Of  the  former,  86  per  cent, 

borne  children,  and  16-09  per  cent,  had   borne  children,  and   14  per 

were  sterile.  cent,  were  barren. 

Menstrual  Function. 

61-5  per  cent,  were  menstruat-  93  per  cent,  were  menstrnating 

ing  when  the  growth  was  first  de-      when  the  tumor  was  first  noticed. 

tected. 

Hereditary  Predisposition. 

Traceable  to  heredity  in  11-28  Do  not  appear  to  be  inherited, 

per  cent,  of  all  cases, 

Ivjury  and  other  Exciting  Causes. 

The  influence  of  trauma  is  seen  Ascribable   to  injury  in  11-94 

in  11-70  per  cent,  of  all  instances,  per  cent,  of  all  cases,  and  to  ecze- 

There  was    an   antecedent   lump  ma  in  1-44  per  cent.     In  1*44  per 

after  puerperal  mastitis  in  821  per  cent,  there  was  antecedent -masti- 

cent.,  and  eczema  of  the  nipple  in  tis. 
1-03  per  cent.,  of  all  cases, 

'  The  conclusions  are  drawn  from  an  analysis  of  712  cases. 
'  Based  upon  a  study  of  138  cases. 


DIAGNOSIS.  199 

Situation. 

Most  common  at    upper  and  Usually  at  the  upper  and  inner 

outer  margin,  and  not  infrequent     circumference.     Rarely  near  the 
near  the  nipple.  nipple. 


Outline. 

Irregular,     slightly    tuberous,  Round,   ovoid,   rarely  discoid, 

knotted    or    knobby,    frequently  lobed,  bossed,  or  nodular,  and  dis- 

discoid,  and  merged  into  the  sur-  tinctly  circumscribed. 
rounding  tissues. 

ConsisteTice. 

Uniformly  densely  hard  and  in-  All  are  firm  or  hard  at  first,  and 
elastic  throughout,  except  in  rare  frequently  elastic;  but  not  a  few- 
instances  of  combination  with  an  are  soft  later.  Many  are  of  unequal 
involution  cyst,  when  there  is  a  consistence,  when  they  have  exist- 
limited  spot  of  fluctuation.  As  an  ed  for  some  time,  in  which  event 
exception,  may  be  firm  and  elastic,  they  are  hard  at  some  points,  and 
or  even  soft  and  fluctuating.  soft,  or  even  fluctuating,  at  others. 


Multiplicity. 

Several  tumors  are  present  in  Several  tumors  present  in  the 

the  same  breast  in  2  per  cent,  of     same  breast  in  5*97  per  cent,  of  all 
all  cases.  cases. 

Volume  and  Rate  of  Growth. 

Kever  reach  the  dimensions  of  May  attain  a  huge  size.    Fre- 

the  simple   tumors,   and    usually  quently  increase  by  fits  and  starts ; 

smaller  than  the  breast  which  they  grow  comparatively  rapidly  ;    and 

have  replaced.     Grow  continuous-  do  not,    except  in   rare   cases   of 

ly  and  comparatively  slowly,  and  fibroma,  undergo  cicatricial  atro- 

are  quite  liable  to  shrivelling  of  the  phy. 
stroma,  particularly  when  they  oc- 
cur late  in  life. 

Mobility. 

Move  with  the  gland  of  which  Glide  and  roll  under  the  fingers, 
they  form  a  part,  and  cannot  be  and  move  freely  within  the  mam- 
isolated.  Attachments  to  the  skin  ma  and  on  the  adjacent  parts;  or, 
and  chest  are  common  and  fre-  if  there  be  attachments,  which  are 
quently  extensive.  exceptional,  they  are  limited. 


200  TUMORS   OF  TEE  MAMMARY  GLAND. 

Relations  to  Breast. 


If  the  tumor  develops  within 
the  substance  of  the  mamma,  the 
latter  is  replaced  by  it,  and  its 
structure  is  destroyed.  "When  it 
begins  at  the  periphery,  the  gland 
is  always  finally  invaded. 


Now  and  then  attached  to  the 
breast  by  a  pedicle ;  but  the  gland 
is  usually  pushed  to  one  side,  spread 
out,  or  atrophied,  and  rarely  in- 
vaded. 


State  of  the  Nipple. 


The  nipple  is  permanently  re- 
tracted and  fixed  in  52  per  cent, 
of  all  cases,  and  is  often  infiltrated. 


The  mammilla,  in  5'22  per  cent, 
of  all  instances,  is  displaced,  bur- 
ied, or  sunken,  by  the  growth  of 
the  tumor  beyond  its  level.  Hence 
it  is  mobile  and  not  truly  retract- 
ed, and  it  is  not  infiltrated. 


Discharge  from  the  Nipple. 


A  thin  sanguinolent  discharge 
is  met  with  in  9  per  cent,  of  all 
cases,  but  it  is  never  copious. 


A  discharge,  usually  of  a  mu- 
coid nature,  is  seen  in  8'95  per 
cent,  of  all  instances ;  and  the  es- 
cape of  a  bloody  fluid  favors  the 
idea  of  vascular  vegetations  in  di- 
lated ducts. 


Superficial  Veins. 

The    subcutaneous    veins     are  The  superficial  veins  are  en- 

somewhat  prominent  in  2  per  cent,      larged  and  prominent  in  13"43  per 
of  all  cases.  cent,  of  all  examples. 


Condition 

The  skin,  even  when  the  tumor 
is  not  larger  than  a  hazel-nut,  pro- 
vided it  be  superficial,  is  dimpled 
and  adherent.  In  larger  growths, 
it  is  adherent,  thinned,  or  discol- 
ored, or  rigid  and  brawny  from 
specific  infiltration,  in  34"54  per 
cent,  of  all  cases,  and  the  seat  of 
distinct  nodules  in  10-61  per  cent. 


of  the  Skin. 

The  skin  is  natural  when  the 
tumor  is  of  moderate  dimensions, 
but  thinned  and  stretched,  or  dis- 
colored, or  adherent,  in  3 1*34  per 
cent,  when  the  neoplasm  is  volumi- 
nous. It  is  never  dimpled  nor  the 
seat  of  secondary  tubers. 


DIAGNOSIS. 

Fixation  to  the  Chest. 


201 


The  tumor  is  attached  to  the 
pectoral  muscle  or  tTiorax  in  21*58 
per  cent,  of  all  instances. 


The  tumor  adheres  to  the  sub- 
jacent structures  in  2"98  per  cent. 
of  all  cases. 


Both  Breasts  affected. 


The  disease  extends  to  the  op- 
posite breast  in  3'65  per  cent,  of 
all  examples,  but  never  before  in- 
fection of  the  skin  and  the  lym- 
phatic glands. 


The  other  mamma  contains  a 
similar  growth  in  5-22  per  cent,  of 
all  cases,  but  without  antecedent 
skin  or  gland  involvement. 


Ulceration. 


The  formation  of  an  \ilcer  en- 
sues, comparatively  early,  in  23*77 
per  cent,  of  all  cases.  The  edges 
of  the  sore  are  everted,  thick,  and 
indurated,  and  adherent  to  the 
hardened  base.  It  never  attains 
the  size  met  with  in  the  simple  tu- 
mor, does  not  fungate,  nor  does  it 
cicatrize  to  any  great  extent. 


Ulceration,  or  limited  gangrene, 
of  the  stretched  and  thinned  inte- 
guments occurs,  late  in  the  disease, 
in  16-41  per  cent,  of  all  instances. 
It  is  generally  attended  with  the 
protrusion  of  a  pedunculated  fun- 
gus, which  is  not  attached  to  the 
margins  of  the  ulcer,  the  edges  of 
which  are  smooth,  even,  and  not 
discolored  or  infiltrated.  The  base 
is  usually  composed  of  intracana- 
licnlar  vegetations,  and  it  now  and 
then  heals. 


Lymphatic  Glands. 


The  axillary  glands  are  enlarged 
and  hard,  when  the  patient  first 
comes  under  observation,  in  64*23 
per  cent,  of  all  cases ;  and  in  1 
out  of  every  22  instances  the  glands 
of  the  neck  are  also  involved. 


Enlargement  of  the  glands  of 
the  axilla  is  met  with  in  2*98  per 
cent,  of  all  examples ;  but  it  is  due 
almost  solely  to  irritative  changes, 
and  they  are  not  hard.  The  su- 
praclavicular glands  are  never  im- 
plicated. 


General  Condition. 


The  general  health  of  the  pa- 
tients is,  as  a  rule,  wonderfully 
good  when  they  first  come  under 
observation. 


The  same  statement  is  true  of 
the  non-carcinomatous  growths. 


202  TUMORS  OF  THE  MAMMARY  GLAND. 

Local  Recurrence. 
Reproduction  after  operation  is  The  tumor  recurs  after  extirpa- 

met  with  in  80"97  per  cent,  of  all      tion  in  27*05  per  cent,  of  all  in- 
cases, stances. 

Duration  of  Life. 
The  average  life  from  the  first  The  average  life  is  rather  more 

observation  of  the  disease  to  the      than  seventy-two  months ;  but  the 
final  report   after  its  removal  is     majority  of  the  subjects  were  still 
forty  months;  but  the  majority  of     living, 
the  patients  were  dead. 

In  tlie  differential  diao-nosis  of  tlie  cancerous  and 
so-called  benign  neoplasms  the  deductions  based  upon 
the  study  of  their  etiology  are,  as  I  pointed  out 
in  Chapter  III,  for  the  most  part,  without  value. 
Hereditary  predisposition,  when  it  can  be  traced,  is 
an  antecedent  which  favors  the  idea  of  carcinoma; 
but  it  must  not  be  forgotten  that  the  most  innocent 
formation,  as  in  the  case  of  a  retention  cyst  occurring 
in  a  lady  forty-three  years  of  age  who  was  recently 
under  my  charge,  not  infrequently  occurs  in  the 
daughter  of  a  cancerous  mother.  So,  too,  the  de- 
velopment of  a  tumor  after  the  age  of  forty  out  of 
an  induration  left  by  puerperal  mastitis  points  to 
cancer,  as  that  condition  antedated  8*21  j)er  cent,  of 
the  carcinomatous,  and  only  1*44  per  cent,  of  the  non- 
carcinomatous  growths. 

Age,  as  an  indication  of  the  anatomical  arrange- 
ment of  the  component  tissues  of  the  mamma,  is,  as 
I  showed  at  page  34,  so  important  an  aid  in  the 
diagnosis  that  a  neoplasm  occurring  before  the  twen- 
tieth year  may  safely  be  pronounced  to  belong  to  the 
non-carcinomatous  group,  while  the  chances  in  favor 
of  carcinoma  are  as  twelve  to  one  after  the  age  of 
forty.     To  be  more  exact,  I  have  framed  the  follow- 


DIAGNOSIS.  203 

ing  conclusions  in  regard  to  tlie  structural  develop- 
ment of  the  mamma,  as  manifested  by  the  age  of  the 
patients,  and  the  development  of  its  neoplasms : 

First.  During  the  rudimentary  condition  of  the 
organ  almost  the  only  growth  met  with  is  fibroma. 

Secondly.  AVhen  the  glandular  structure  is  being 
evolved,  after  the  appearance  of  the  menses,  and  the 
connective  tissue  is  still  in  excess,  fibroma  and  fibrous 
sarcoma  are  the  most  common  growths. 

Thirdly.  At  the  epoch  of  and  after  the  first  preg- 
nancy, that  is,  between  twenty  and  thirty  years,  when 
the  glandular  structure  is  perfected  and  the  connec- 
tive tissue  is  vascular,  succulent,  and  rich  in  cells, 
fibromata  and  small  round-celled,  or  small  spindle- 
celled  sarcomata,  which  are  equivalent  to  medullary 
sarcomata,  are  to  be  anticipated. 

Fourtlily.  From  the  thirtieth  to  the  fortieth  year, 
or  during  the  stage  of  passive  maturity,  cystic  sarco- 
mata and  cystic  fibromata  are  most  frequently  met 
^^dth,  and  true  adenoma  is  also  most  common. 

Lastly.  During  the  period  of  involution,  when 
the  lacteal  glands  are  disappearing,  and  the  connec- 
tive and  adipose  tissues  are  becoming  abundant, 
myxoma  and  carcinoma  make  their  appearance. 

Of  the  symptoms  themselves,  valuable  informa- 
tion is  to  be  derived  from  the  consistence,  dimen- 
sions, isolation,  and  mobility  of  the  growth,  as  well 
as  from  the  condition  of  the  skin,  the  nipple,  the  sub- 
cutaneous veins,  and  the  associated  glands.  As  the 
majority  of  these  signs  were  sufficiently  dwelt  upon 
in  the  chapters  on  the  individual  neoplasms  and  in 
the  preceding  table,  I  will  only  dii^ect  attention  to 
those  which  are  the  most  important. 


204  TUMORS  OF  THE  MAMMARY  GLAND. 

In  tlie  non-carcinomatous  tumors  tlie  skin,  while 
it  may  be  tliinned,  stretclied,  and  discolored,  or  some- 
what adherent,  is  rarely  invaded  by  cell  infiltration, 
and  is  never  the  seat  of  distinct  nodules  or  tubers. 
In  carcinoma,  on  the  other  hand,  its  infiltration  by 
advancing  epithelial  cells  gives  rise  to  a  hard,  brawny 
condition,  which  is  very  characteristic,  or  to  exten- 
sive adhesion,  or  discoloration,  or  to  distinct  tubers ; 
and  it  is  not  infrequently  pervaded  by  beaded  or 
varicose  Ipnphatics,  which,  as  far  as  I  know,  are 
never  seen  in  the  opposite  class  of  tumors. 

While  ulceration  is  less  frequent  in  the  non-carci- 
nomatous than  in  the  carcinomatous  grovii;hs,  it  also 
arises  in  a  very  different  way,  and  has  certain  pecu- 
liarities which  are  distinctive.  Thus,  it  is  the  almost 
invariable  result  of  limited  gangrene  of  the  thinned 
and  stretched,  but  not  infiltrated,  skin ;  while  its 
edges  are  smooth,  soft,  and  sometimes  elevated  upon 
the  fungus  which  protrudes  through,  without  being 
attached  to  it.  Such  an  appearance  is  peculiar  to  the 
non-carcinomatous  growths,  and  is  of  itself  quite  suf- 
ficient to  exclude  the  idea  of  carcinoma. 

The  nipple  is  permanently  retracted  in  more  than 
one-half  of  the  cases  of  carcinoma,  while  it  is  sunken, 
by  the  protrusion  of  the  tumor  beyond  its  level,  in 
only  one  out  of  every  twenty  of  the  non-carcinoma- 
tous neoplasms.  This  contrast  is  most  striking ;  but 
it  is  not  more  so  than  one  might  expect,  if  the 
contracting  nature  of  carcinoma  is  borne  in  mind. 
When,  in  addition  to  the  retraction,  the  mammilla  is 
also  fixed  and  indurated,  these  conditions  may  almost 
be  regarded  as  pathognomonic  of  carcinoma.  Dis- 
charge from  the  nipple  merely  indicates   that   the 


I 


DIAGNOSIS.  205 

glandular  structure  is  involved,  either  primarily  or 
secondarily,  and  that  one  or  more  of  the  ducts  lead- 
ing from  the  secreting  lobules  are  permeable.  When 
it  antedates  the  detection  of  a  tumor,  there  is  every 
probability  that  the  growth  is  an  adenoma.  If  the 
neoplasm  has  a  solid  and  hard  feel,  it  is  probably  a 
carcinoma,  since  a  discharge  is  only  met  with  in  the 
cystic  non-carcinomatous  tumors. 

Fixation,  or  adhesion,  to  the  walls  of  the  chest  is 
a  valuable  symptom  of  carcinoma,  inasmuch  as  it  is 
ten  times  more  frequent,  and  far  more  extensive,  than 
in  the  opposite  class  of  growths. 

Of  all  the  signs,  there  is  none  which  is  so  valuable 
in  the  differentiation  as  the  state  of  those  lymphatic 
glands  which  are  in  anatomical  connection  with  the 
breast.  Thus,  in  every  one  hundred  cases  of  carci- 
noma, when  the  patient  first  comes  under  observation 
the  axillary  glands  will  be  found  to  be  enlarged  and 
indurated  in  sixty-four,  and  in  nearly  one-third  of 
these  the  glands  above  the  clavicle  "will  also  be  con- 
taminated. Of  the  non-carcinomatous  tumors,  on  the 
other  hand,  out  of  every  one  hundred  cases,  in  only 
three  are  the  axillary  glands  enlarged,  while  they 
are  never  densely  hard.  The  glands  above  the  clav- 
icle are  never  implicated. 

The  diagnosis  of  the  non-carcinomatous  neoplasms 
is  based,  therefore,  upon  their  occurrence  in  one  case 
out  of  every  six  and  two-thirds  before  the  age  of 
twenty ;  their  greatest  frequency  before  the  fortieth 
year ;  their  multiplicity  in  one  breast ;  their  circum- 
scribed, rounded,  or  ovoid  and  bossed  outline ;  the 
firm  consistence  of  the  smaller  and  the  unequal  feel 
of  the  larger ;  their  mobility  in  or  on  the  breast  and 


206  TUMORS  OF  THE  MAMMARY  GLAND. 

tlie  adjacent  tissues  ;  their  comparatively  rapid  growth 
and  large  volume ;  the  almost  normal  appearance  of 
the  skin ;  the  enlargement  of  the  superficial  veins 
when  they  are  bulky  ;  their  tendency  to  ulcerate  and 
fungate  late  in  the  disease  ;  the  absence  of  adhesions 
between  the  protrusion  and  the  circular,  and  as  it 
were  punched-out,  margins  of  the  ulcer ;  and,  finally, 
their  exemption  from  a  histoiy  of  hereditary  predis- 
position, from  retraction  of  the  nipple,  and  from  en- 
largement of  the  associated  lymphatic  glands. 

The  points  in  favor  of  carcinoma  are  a  history  of 
heredity ;  non-development  before  the  twentieth  year ; 
greatest  frequency  after  the  fortieth  year ;  irregular, 
knobby  outline ;  uniformly  densely  hard  consistence ; 
immobility  in  the  breast ;  relatively  small  volume  and 
slow  growth ;  retraction  of  the  nipple ;  enlargement 
and  induration  of  the  lymphatic  glands ;  invasion  of 
the  skin ;  fixation  to  the  pectoral  muscle  or  walls  of 
the  chest;  limited  ulceration,  late  in  the  disease, 
mthout  any  tendency  to  fungous  protrusion ;  and 
the  thickened,  indurated,  and  everted  edges  of  the 
ulcer. 

The  gross  anatomical  characters  of  these  two 
classes  of  neoplasms  are  sufficiently  characteristic  for 
diagnostic  purposes.  The  carcinomatous  are  not  sur- 
rounded by  a  limiting  capsule,  so  that  their  attach- 
ments are  so  close  that  they  are  with  difficulty  freed 
from  the  adjacent  skin,  fat,  fasciae,  and  muscles.  On 
section,  they  are  firm,  crisp,  tough,  and  often  ci'eak 
under  the  knife.  Their  cut  surfaces  assume  a  con- 
cave appearance,  are  not  lobed  or  cystic,  and  cannot 
be  torn  into  small  bundles ;  and  their  gi^ayish  basis 
is  traversed  by  minute  points  of  fat  or  by  yellow 


DIAGNOSIS.  207 

lines,  wliicli  represent  tlie  remains  of  ducts  with  tlieir 
contents  in  a  state  of  fatty  degeneration.  They  are 
also  frequently  pervaded  by  glistening  white  fibrous 
bands,  so  as  to  look  like  the  section  of  an  unripe  pear ; 
and  a  pultaceous,  milky  fluid  exudes  from  them  on 
pressure  or  scraping. 

The  non-carcinomatous  neoplasms  are  surrounded 
by  a  fibrous  capsule,  through  which  they  can  readily 
be  detached  from  the  surrounding  tissues.  Although 
they  may  be  tough,  they  rarely  creak  on  section,  and 
their  divided  surfaces  are  plane,  or  they  may  even  be 
prominent,  but  are  never  concave.  Many,  and  par- 
ticularly the  sarcomata,  have  a  fibrous  tear,  which  is 
very  characteristic,  and  not  a  few  are  Ipbed.  They 
are  not  streaked  by  yellowish  lines,  nor  do  they  con- 
tain pellets  of  fat.  They  are,  moreover,  fi^equently 
the  seat  of  dilated  ducts  and  vegetations,  and  exude 
a  serous  fluid  on  pressure.  An  open-mouthed  duct, 
or  a  small  cyst  or  two,  may  be  found  in  carcinoma, 
but  these  are,  with  very  rare  exceptions,  free  from 
vegetations.  On  the  whole,  the  presence  of  a  limit- 
ing capsule  and  of  enlarged  ducts  and  vegetations, 
and  the  absence  of  fat  and  concavity  on  section,  are 
quite  sufficient  to  distinguish  the  non-carcinomatous 
from  the  carcinomatous  tumors. 

Having  convinced  himself  of  the  non-carcinoma- 
tous nature  of  the  neoplasm,  the  surgeon  has  still 
before  him  the  solution  of  the  problem  as  to  whether 
it  is  solid  or  cystic.  Although  the  latter  merely  rep- 
resents a  further  stage  of  evolution  of  the  former, 
there  are  some  important  points  of  difference  between 
them  which  render  their  differentiation  comparatively 
easy. 


208  TUMORS  OF  THE  MAMMARY  GLAND. 

NON-CARCINOMATOUS  NEOPLASMS. 

Solid  Foem.  Cystic  Foem. 

Age  of  Occurrence. 

Develops,  on  an  average,  at  the  Appears,  on  an  average,  at  the 

thirty-first  year.     8  per  cent,  ap-  thh-ty-fifth  year.    l-75per  cent,  oc- 

pear  before  the  age  of  sixteen ;  56  cur  before  the  sixteenth  year ;  38 

per  cent,  originate  during  the  pe-  per  cent,  develop  between  sixteen 

riod  of  the  perfection  of  the  mam-  and  forty  years ;  and  60  per  cent. 

ma ;  and  36  per  cent,  are  observed  are  witnessed  after  the  age  of  forty, 
during  its  functional  decline. 

Consistence. 

Equable,  whether  it  be  firm  or  Variable  or  unequal,  being  firm 

soft.  at  some  points,  and  soft  or  fluctu- 

ating at  others. 

Volume  and  Rate  of  Growth. 

Increases  slowly,  and  rarely  at-  Grows  quite  rapidly,  and  some- 

tains  a  considerable  bulk.  times  acquires  enormous  dimen- 

»  sions. 

Condition  of  the  Skin. 

The  skin  is  discolored  in  983  The  skin  is  discolored  in  26-02 

per  cent.,  and  adherent  in  819  per      per  cent.,  and  adherent  in   16-43 
cent.,  of  all  instances.  per  cent.,  of  all  cases. 

Superficial  Veins. 

The  subcutaneous  veins  are  en-  The   superficial  veins  are  en- 

larged in  4-91  per  cent,  of  all  cases,      larged  in  17"80  per  cent,  of  all  cases. 

State  of  the  Nip2)le. 

The  nipple  is  buried  or  sunken  The  mammilla  is  depressed  or 

in  1-63  per  cent,  of  all  examples.        sunken  in   8-21   per  cent,  of  all 

instances. 

Discharge  from  the  Nipple. 

Discharge  from   the  nipple  is  The  nipple  discharges  in  16*43 

unknown.  per  cent,  of  all  cases. 


DIAGNOSIS.  209 

Fixation  to  the  Chest. 

The  tumor  is  always  mobile  on  The  growth  is  attached  to  the 

the  chest.  pectoral  muscle  or  ribs  in  4-10  per 

cent,  of  all  instances. 

Ulceration. 

Spontaneous  ulceration  occurs  Spontaneous  ulceration  is  met 

in  16'55  per  cent,  of  aU  cases.  with,  and  generally  with  fungous 

protrusion,  in  2'4"63  per  cent,  of 
all  cases. 

Lymphatic  Glands. 

The  glands  of  the   axiUa  are  The  axillary  glands  are  enlarged 

enlarged  in  1'63  per  cent,  of  all      in  4*10  per  cent,  of  all  cases, 
examples. 

From  the  foregoing  analysis  it  will  be  seen  tliat 
the  solid  tumors  present  themselves  simply  as  cir- 
cumscribed growths,  which  have  an  equable  consis- 
tence, grow  slowly,  are  of  moderate  volume,  and  are 
not  characterized  by  alterations  in  the  associated  or 
contiguous  stnictures.  The  cystic  neo^^lasms,  on  the 
other  hand,  have  a  variable  consistence,  grow  rapidly, 
and  attain  a  large  volume,  and  are  quite  liable  to 
changes  in  the  skin,  prominence  of  the  subcutaneous 
veins,  limited  supei'iicial  adhesions,  spontaneous  ulcer- 
ation and  fungous  protrusion,  and  a  discharge  from 
the  nipple.  When  the  mammilla  is  deformed,  when 
the  tumor  is  partially  fixed  to  the  chest,  and  when 
the  lymphatic  glands  are  swollen,  all  of  these  signs 
are  far  more  frequent  in  the  cystic  than  in  the  solid 
form.  The  preceding  phenomena,  however,  do  not 
occur  with  equal  frequency  in  the  different  solid  and 
cystic  grov/ths,  as  is  set  forth  in  the  following  state- 
ment, which  affords  important  clues  to  their  differen- 
tial diagnosis. 
14 


210 


TUMORS  OF  THE  MAMMARY  GLAND. 


SOLID. 

CYSTIC. 

Fibroma. 

Sarcoma. 

Myxoma. 

Adenoma. 

Fibroma, 

Sarcoma. 

Myxoma. 

Adenoma. 

Average  age  of 

development 

23yrs. 

STyrs. 

45  yrs. 

16  yrs. 

86  yrs. 

83  yrs. 

48  yrs. 

35  yrs. 

The  skin  is  dis- 

colored in . . . 

None. 

16  p.  0. 

40  p.  c. 

None. 

10  p.  c. 

34-28  p.  c. 

83-38  p.  c. 

26-66  p.  c. 

The  veins   are 

enlarged  in.. 

" 

8      » 

20     " 

" 

15    " 

25-Tl    " 

None. 

6-6T    » 

The   nipple    is 

deformed  in . 

" 

None. 

20     " 

" 

10    " 

5-71    " 

" 

18-33    " 

Discharge  from 

the  nipple  in. 

" 

" 

None. 

" 

15     " 

14-28    » 

" 

26-66    " 

Superficial    ad- 

hesions in. . . 

" 

12  p.  c. 

20  p.  c. 

" 

10    " 

8-5T    " 

33-83  p.  c. 

40 

Deep  adhesions 

in 

^^ 

None. 
12  p.  0. 

None. 
20  p.  c. 

„ 

10    » 
10    " 

2-85    " 
81-42    " 

None. 
38-83  p.  c. 

None. 

Ulceration  in . . 

26-66  p.  c. 

Axillary  glands 

enlarged  in . . 

" 

None. 

20     " 

" 

None. 

2-65    " 

None. 

18-33    " 

In  tlie  discrimination  between  the  solid  and  cystic 
growths,  invaluable  aid  may  be  derived  from  the  ex- 
ploring needle  or  a  slight  puncture.  In  the  event  of 
the  tumor  being  solid,  nothing,  save  perhaps  a  little 
blood,  comes  away ;  whereas,  if  it  be  cystic,  the  dis- 
charge of  its  watery  or  sanguinolent  contents  will 
tend  to  diminish  its  volume  very  materially,  and  it 
may  even  be  possible  to  feel  the  solid  vegetations 
which  have  been  obscured  by  the  presence  of  the 
fluid.  From  simple  cysts  of  the  mamma  the  diagno- 
sis rests  upon  the  fact  that  the  cystic  neoplasms  do 
not  entirely  disappear  after  the  evacuation  of  the  cav- 
ities; while  from  chronic  abscess,  which  not  infre- 
quently simulates  a  cystic  growth,  the  distinction  is 
based  upon  a  drop  of  pus  following  the  withdrawal 
of  the  exploring  needle. 

The  differential  diagnosis  of  the  varieties  of  car- 
cinoma may  be  determined  by  attention  to  their  con- 
trasts and  affinities,  which  are  set  forth  in  the  table 
at  page  182. 

Although  the  lines  of  demarcation  between  many 
of  the  tmnors  of  the  mamma  are  not  very  distinct. 


DIAGNOSIS.  211 

yet  a  careful  attention  to  tlieir  more  prominent  signs 
enables  one  to  arrive  at  a  pretty  correct  judgment  as 
to  their  true  nature.  From  an  analysis  of  the  cases 
that  have  occurred  in  my  own  practice,  and  of  those 
collated  from  various  sources,  I  have  framed  the  fol- 
lowino-  conclusions : — 

1.  A  uniformly  hard,  perfectly  movable,  nodular, 
slowly  growing  tumor,  particularly  if  it  be  seated  at 
the  upper  and  outer  part  of  the  gland  of  impubic 
subjects  and  of  married  women  toward  the  twenty- 
third  year,  and  be  free  from  ulceration,  alterations  in 
the  skin,  veins,  nipple,  and  lymphatic  glands,  is  a 
solid  fibroma,  and  the  diagnosis  is  strengthened  by 
the  presence  of  several  growths  in  one  or  both 
breasts. 

2.  A  hard,  lobulated,  peripheral  tumor,  or  one 
which,  after  having  remained  stationary  or  progressed 
slowly  for  several  years,  suddenly  and  rapidly  ac- 
quires a  large  volume,  and  assumes  an  unequal  con- 
sistence, being  firm  at  some  points  and  soft  or  fluctu- 
ating at  others,  and  which  occurs  toward  the  thirty- 
sixth  year,  unaccompanied  by  lymphatic  involvement, 
but  attended,  possibly,  wdth  discoloration  of  the  skin, 
deformity  of  the  nipple,  and  limited  superficial  adhe- 
sions, and  it  may  be  with  dilatation  of  the  veins,  with 
discharge  from  the  nipple,  and  with  ulceration  and 
fungous  protrusion,  is  a  cystic  fibroma. 

3.  A  firm,  rapidly  growing,  peripheral  tumor,  ap- 
pearing in  prolific  married  females  at  about  the 
thirty-seventh  year,  with  possibly  discoloration  and 
adhesion  of  the  skin,  and  ulceration,  but  without 
defonnity  of,  or  discharge  from,  the  nipple,  or  en- 
largement of  the  glands,  is  a  solid  sarcoma.    A  tumor 


212  TUMORS  OF  THE  MAMMARY  GLAND. 

possessing  tliese  attributes,  and  occurring  toward  tlie 
thirty-second  year  is  probably  a  firm  spindle-celled 
sarcoma,  while  one  developing  at  about  the  forty- 
second  year  is  more  apt  to  be  a  fiim  round-celled 
sarcoma. 

4.  A  lobulated  tumor,  particularly  if  it  involves 
the  greater  part  of  the  mamma,  of  quick  growth  from 
the  commencement,  or  progressing  rapidly  after  hav- 
ing increased  comparatively  slowly  for  some  time,  of 
large  size,  of  varying  or  unequal  consistence,  occur- 
ring toward  the  thu'ty -third  year,  in  prolific  married 
subjects,  and  attended  with  discoloration  of  the  skin, 
ulceration,  enlargement  of  the  veins,  and  possibly 
with  discharge  from  the  nipj)le  and  with  limited  ad- 
hesions, or,  it  may  be,  with  deformity  of  the  nipple 
and  glandular  enlargement,  is  a  cystic  sarcoma.  A 
very  rapidly  progressing  tumor,  of  soft,  apparently 
fluctuating  consistence,  with  stretched  skin  and  en- 
larged veins,  appearing  in  young  girls  before  puberty 
and  in  young  married  women,  is  a  medullary  sar- 
coma, which  may  be  solid  or  cystic,  and  which  is,  as 
a  rule,  composed  of  small  spindle  cells. 

5.  A  solitary,  rapidly  and  continuously  growing, 
although  not  very  bulky,  rather  firm,  or  j)ossibly  soft 
tumor,  occurring  at  about  the  forty-fifth  year,  with 
limited  discoloration  of  the  skin,  but  not  fixed  to  the 
chest,  and  attended  possibly  with  defonnity  of  the 
nipple,  superfcial  adhesions,  ulceration,  dilatation  of 
the  veins,  and  enlargement  of  the  axillary  glands,  is 
a  solid  myxoma. 

6.  Cystic  myxoma  possesses  the  same  consistence 
and  growing  attributes  of  the  foiTaer  variety,  but  it 
develops  at  about  the  forty-eighth  year^  and  is  liable 


DIAGNOSIS.  213 

to  be  attended  witli  discoloration,  adhesion,  and  ul- 
ceration of  the  skin.  The  veins,  nipple,  and  glands, 
however,  are  normal. 

7.  A  hard,  heavy,  nodular,  solitary,  veiy  slowly 
and  equably  increasing  tumor,  especially  if  it  de- 
velops in  the  immediate  vicinity  of  the  nipple  of  a 
married  woman  toward  the  thiii;y-fifth  year,  and  is 
accompanied  by  adhesion  and  discoloration  of  the 
skin,  and  by  ulceration,  and  possibly  by  deformity 
of  the  nipple  and  enlargement  of  the  glands,  but  is 
free  from  fixation  to  the  chest  and  dilatation  of  the 
veins,  and  is  preceded  by  a  discharge  from  the  nip- 
ple, is  a  cystic  adenoma.  A  solid  adenoma  cannot  be 
distinsruished  from  a  solid  fibroma. 

8.  A  densely  hard,  inelastic,  irregular,  solitary, 
slowly  grooving  tumor,  occuiTing  in  prolific  married 
females  toward  the  forty-eighth  year,  inseparably 
connected  ^^dth  the  mamma,  accompanied  by  indura- 
tion and  enlargement  of  the  associated  lymphatic 
glands,  retraction  of  the  nipple,  infiltration  of,  and 
possibly  nodules  in,  the  skin,  ulceration,  and  fixation 
to  the  chest,  and  it  may  be  by  a  discharge  from  the 
nipple,  is  a  scirrhous  carcinoma ;  and  the  diagnosis  is 
strengthened,  if  there  be  a  history  of  heredity,  should 
the  tumor  be  preceded  by  psoriasis  or  eczema  of  the 
nipple,  or  should  it  be  developed  from  an  induration 
left  by  puerperal  mastitis. 

9.  A  soft,  lobulated,  voluminous,  solitary,  and 
rapidly  increasing  tumor,  occuiTing  in  the  same  class 
of  women,  at  about  the  fiftieth  year,  and  attended 
with  infection  of  the  glands  and  skin,  retraction  of 
the  nipple,  fixation  to  the  chest,  and  possibly  exten- 
sion to  the  opposite  breast,  but  without  discharge 


214  TUMORS  OF  THE  MAMMARY  GLAND. 

from  tlie  nipple,  or  without  raarkecl  tendency  to 
prominence  of  tlie  veins  or  ulceration,  is  a  medullary 
or  encephaloid  carcinoma. 

10.  A  hard,  very  slowly  growing,  small,  solitary 
tumor,  occurring  toward  the  forty-fifth  year,  with  ad- 
hesion to  the  skin,  and  it  may  be  nodules  in  that 
structure,  prominence  of  the  veins,  retraction  of  the 
nipple,  and  enlargement  of  the  glands,  and  possibly 
with  invasion  of  the  opposite  breast,  fixation  to  the 
chest,  ulceration,  and  discharge  from  the  nipple,  is  a 
colloid  carcinoma. 

11.  A  densely  hard,  irregular  and  knotty,  con- 
tracting and  small,  solitary  tumor,  occurring  at  about 
the  forty-seventh  year,  and  attended  with  retraction 
of  the  nipple,  infection  of  the  glands  and  skin,  and 
possibly  distinct  tubers  in  the  skin,  ulceration,  and 
immobility  on  the  chest,  is  an  atrophying  scirrhus. 

12.  A  slowly  increasing,  solitary,  nodular,  or 
slightly  lobulated  tumor,  occurring  after  the  meno- 
pause, covered  by  thinned  and  discolored  skin,  fluc- 
tuating, and  probably  discharging  by  the  nipple,  but 
without  enlargement  of  the  veins  or  glands,  and  with- 
out fixation  to  the  chest,  is  an  involution  cyst. 

13.  A  solitary,  smooth,  firm  and  elastic,  or  possi- 
bly fluctuating  tumor,  occurring  in  the  vicinity  of 
the  nipple  of  young  and  prolific  married  women,  of 
moderate  volume,  of  slow  growth,  and  unattended 
with  alterations  in  the  veins,  nipple,  skin,  or  glands, 
or  Avith  adhesions,  but  liable  to  ulceration  and  en- 
largement of  the  glands  if  it  inflames,  is  an  evolution 
cyst. 

14.  A  solitary,  slowly  growing,  not  bulky,  fluctu- 
ating, or  semisolid  tumor  occurring  near  the  nipple 


\ 


DIAQNOSIS.  215 

of  lactatino;  women,  and  unattended  mtli  chansres  in 
tlie  coverings  of  tlie  mamma  or  in  tlie  glands,  is  a 
lacteal  cyst. 

15.  A  slowly  growing,  small,  smooth,  round,  firm 
and  elastic,  or  fluctuating,  solitary  tumor,  occuriing 
between  the  ages  of  twenty  and  tliirty  years,  seated 
at  tlie  upper  and  outer  border  of  the  breast,  and  not 
near  the  mammilla,  with  a  disposition  to  ulcerate,  but 
mthout  other  changes  in  the  skin,  veins,  or  glands,  is 
an  hydatid  cyst. 


CHAPTEK    XII. 

THE  TREATMENT  OF  TUMORS  OF  TEE  MAMMARY  GLAND. 

The  management  of  mammaiy  neoplasms  should 
be  based  solely  upon  the  conclusions  drawn  from  the 
prominent  facts  in  their  life,  which  we  have  now 
learned  in  studying  their  general  pathology.  Those 
in  resrard  to  which  there  is  the  most  hesitation  in 
practising  an  operation  are  the  small,  circumscribed, 
mobile  growths  which  are  so  frequently  met  with 
toward  the  periphery  of  the  gland,  and  which  may 
remain  stationaiy  for  a  number  of  years.  Among  the 
older  records  there  are  statements  to  the  effect  that 
they  may  disappear  after  marriage,  or  during  preg- 
nancy, or  even  at  the  period  of  the  menopause ;  but 
this  occurrence  is  so  exceptional  that  the  resources  of 
nature  alone  cannot  be  relied  upon.  My  o^\ti  expe- 
rience in  this  direction  is  limited,  and  of  a  negative 
character.  I  have  now  under  observation  two  young 
married  women  w^ho  are  affected  with  firm,  elastic, 
bossed,  irregular  nodules,  which  are  perfectly  mobile 
upon  and  under  the  contiguous  structures,  but  are 
closely  attached  to  the  gland,  and  w^hich  doubtless 
represent  fibromata,  or  possibly  adenomata.  In  one 
of  the  patients  there  are  two  peripheral  tubers  in  the 
right  and  one  in  the  left  breast.  Twenty  months  ago 
she  gave  birth  to  and  nourished  a  child,  but  there 


TREATMENT.  217 

has  been  no  appreciable  cliange  in  tlie  volume  of  the 
growths.  In  the  second  case,  a  hard,  lobulated  nod- 
ule of  the  size  of  a  hickory-nut  is  seated  above  and 
to  the  inside  of  the  nipple.  She  also  had  been  led  to 
believe  that  it  would  probably  disappear  after  mar- 
riage, but  now,  fourteen  months  after  parturition,  it 
retains  its  former  dimensions. 

Should  the  surgeon  or  the  subject  be  averse  to  an 
operation,  methodical  compression  with  pads  of  agaric 
or  an  air-cushion  holds  out  some  hopes  of  success. 
Thus  Broca'  regards  compression  as  a  very  effica- 
cious measure ;  and,  although  he  records  nine  cases 
in  which  the  growth  disappeared,  the  majority  sub- 
jected to  this  tedious  and  annoying  remedy  were 
only  partial  cures,  a  small  nodule  remaining  behind 
after  the  cessation  of  the  treatment.  Erichsen,'  too, 
speaks  well  of  it ;  but,  with  these  exceptions,  it  does 
not  appear  to  have  met  with  favor. 

On  several  occasions  I  employed  the  gum  ammo- 
niac and  mercurial  plaster,  with  the  result  of  causing 
the  absorption  of  the  pericapsular  fat,  but  without 
any  effect  upon  the  tumor  itself.  The  inunction  of 
stimulating  and  sorbefacient  ointments  is  not  only 
useless,  but  it  is  liable  to  prove  irritating,  and  awaken 
the  growth  into  activity. 

Since  little  can  be  expected  from  local  measures, 
are  these  small  neoplasms  to  be  let  alone  from  the 
mere  fact  that  they  are  quiescent  ?  While  it  may  be 
true  that  no  harm  will  result  from  such  advice,  it  is 
more  likely  to  be  true  that  hai-m  mil  ensue ;  and  I 
doubt  not  that  many  surgeons  can  recall  to  mind 
cases  of   large,  ulcerated,  fungous,  offensive  masses 

*  Op.  cit.,  vol.  ii,  p.  462.  '  Op.  cit.,  vol.  ii,  pp.  564  and  578. 


218  TUMORS  OF  TEE  MAMMARY  OLAND. 

wMch  could  liave  been  prevented  by  an  early  opera- 
tion. In  tbe  Second  Chapter  I  direct  attention  to 
the  fact  that,  although  they  may  remain  of  apparent- 
ly little  importance  for  many  years,  they  exhibit  a 
tendency  to  change  their  nature,  so  that  a  pure  fibro- 
ma may  be  the  starting-point  of  a  sarcoma,  an  ade- 
noid fibroma  and  an  adenoma  may  pass  into  a  carci- 
noma, and  a  lipoma  may  be  converted  into  a  myxoma. 
For  these  practical  truths  we  are  indebted  to  modem 
histological  researches,  and  the  lesson  which  they 
convey  is  one  that  should  not  pass  unheeded.  All 
of  the  encapsuled  or  non-carcinomatous  mammary 
tumors  in  the  early  stages  of  their  development  pos- 
sess so  many  features  in  common  that  their  differen- 
tiation is  a  matter  of  such  difiiculty  that  it  is  by  no 
means  possible  to  say  categorically  which  is  a  fibro- 
ma, which  a  sarcoma,  which  a  myxoma,  and  which  an 
adenoma,  so  that,  if  an  error  in  judgment  be  commit- 
ted, it  had  best  be  on  the  safe  side,  and  all  small 
tumors  of  the  mamma  without  exception  should  be 
enucleated,  an  operation  that  can  be  performed  with- 
out materially  interfering  with  the  body  of  the  mam- 
ma itself,  and  can  be  so  conducted  as  to  spare  the 
nipple. 

As  fibrous  tumors  are  absolutely  innocent,  if  their 
true  nature  be  determined,  they  may  be  let  alone ;  but 
my  advice  is  that  they  be  extii-pated  if  they  begin  to 
grow.  In  point  of  fact,  the  conservative  surgeon 
should  remember  that  a  progressively  increasing  tu- 
mor is  to  be  extirpated,  and  that  no  time  is  to  be  lost 
in  deciding  upon  its  intimate  nature.  My  own  ex- 
perience '  has  convinced  me  that  a  tumor,  not  a  carci- 

'  Phila.  Med.  Times,  vol.  viii,  p.  82. 


TREATMENT.  219 

noma,  wliicli  attains  tlie  volume  of  a  walnut  in  six 
or  seven  months  is  a  fibrous  sarcoma,  and  that  it 
should  be  subjected  to  the  knife.  As  small  growths 
of  this  description,  occurring  in  young  subjects,  ex- 
hibit little  tendency  to  recur,  there  is  no  necessity  for 
sacrificing  the  entire  breast. 

If,  for  any  reason  whatever,  a  small  circumscribed 
neoplasm  be  not  interfered  with,  the  surgeon  need  not 
be  sui-prised  if  it  finally  becomes  cystic,  attains  large 
dimensions,  is  a  source  of  annoyance  through  its  bulk 
and  weight,  is  harassing  fi*om  the  suifering  mth 
which  it  is  attended,  and  ulcerates  and  wears  away 
life  through  spoliative  discharges  and  the  inhalation  of 
foul  odors.  Under  these  cii'cumstances  he  may  have  to 
deal  with  a  cystic  fibroma,  sarcoma,  myxoma,  or  ade- 
noma, and  upon  his  diagnosis  will  depend  the  extent 
of  the  operation  to  which  the  patient  must  be  sub- 
jected. If  he  is  in  doubt  as  to  the  true  nature  of  the 
neoplasm,  he  may  be  aided  by  the  emplo}Tnent  of  the 
freezing  microtome,  since  with  this  contrivance  sec- 
tions can  be  made  and  submitted  to  minute  examina- 
tion before  he  has  finished  taking  up  the  bleeding  ves- 
sels. On  this  account  the  instrument  is  invaluable, 
and  should  be  found  at  least  in  the  operating  room  of 
every  hospital.  Whatever  may  be  the  nature  of  the 
growth,  the  entire  breast  should  be  removed  wdth  it. 
Should  it  turn  out  to  be  a  fibroma,  the  prognosis  is  so 
favorable  that  nothing  more  need  be  done ;  but,  if  the 
tumor  proves  to  be  a  myxoma  or  sarcoma,  the  surgeon 
should  remember  that  either  is  excessively  liable  to 
return  in  consequence  of  the  invasion  of  the  adjacent 
tissues  along  the  line  of  the  bloodvessels,  even  thoiigh 
there  are  no  visible  areas  of  infection.     Hence  it  be- 


220  TUMORS  OF  THE  MAMMARY  GLAND. 

comes  liis  duty  to  search  for  any  outlying  lobules  of 
tlie  gland  that  may  have  escaped  the  knife ;  to  dissect 
off  the  fascia  of  the  pectoral  muscle ;  and  to  clear  out 
the  axilla  entirely  in  the  event  of  that  space  contain- 
ing any  enlarged  glands.  In  myxoma  the  adhesion 
of  the  skin  is  due  to  its  infiltration  by  tumor  elements, 
so  that  if  that  stiiicture  be  attached  it  should  be  re- 
moved with  no  sparing  hand.  If  the  underlying  pec- 
toral or  intercostal  muscles  are  invaded,  the  diseased 
structures  should  be  removed  for  at  least  an  inch  be- 
yond the  apparent  limits  of  the  nodules ;  in  a  word, 
the  operation  should  be  thorough  in  every  respect. 
If  under  the  microscope  the  growth  should  prove  to 
be  a  true  adenoma,  the  removal  of  the  entire  mamma 
will  suffice,  along  with  any  enlarged  lymphatic  glands 
that  may  be  found  in  the  axilla.  Another  good  rule 
is  to  sacrifice  the  breast  when  it  is  the  seat  of  multi- 
ple tumors,  as  in  this  way  recurrence  may  be  avoided. 
As  a  prevention  against  local  reproduction,  in  the  case 
of  sarcoma  and  myxoma,  the  entire  denuded  surface 
should  be  mopped  mth  a  strong  solution  of  chloride 
of  zinc,  or  even  seared  ^vith  the  cautery  at  red  heat. 

After  recovery  the  patient  should  be  cautioned  to 
see  her  attendant  from  time  to  time,  in  order  that  re- 
current growths  may  be  extirpated  as  rapidly  as  they 
appear  and  before  they  have  acquired  any  considera- 
ble size.  In  a  case  of  a  small  spindle-celled  sarcoma 
Gross  succeeded,  after  removing  fifty-two  tumors,  by 
twenty-three  distinct  operations,  the  last  few  of  which 
included  portions  of  the  pectoral  and  intercostal  mus- 
cles, in  a  period  of  four  years  and  a  half,  in  checking 
the  reproductions,  and  the  patient  was  perfectly  well 
nearly  eleven  years  subsequently.     Gay  had  added 


TREATMENT.  221 

nine  years  to  his  patient's  life  at  tlie  date  of  the  last  re- 
port ;  and  Heath  and  Haward,  in  similar  cases,  removed 
numerous  recurrent  tumors  in  thirteen  years.  These 
illustrations  demonstrate  what  may  be  accomplished 
by  exercising  great  vigilance,  and  by  cutting  with  a 
bold  hand ;  and  I  have  no  doubt  that  the  medullary 
sarcomata  of  young  persons,  which  attain  a  large  bulk 
in  a  few  months,  and  are  the  most  fatal  of  all  tumors 
of  the  breast,  would  yield  to  treatment  if  the  entire 
organ,  including  its  investments,  were  amputated  bod- 
ily, the  pectoral  fascia  dissected  off,  and  the  exposed 
muscles  thoroughly  seared  with  the  hot  iron.  These 
cases  are  desperate,  and  do  not  admit  of  mild  mea- 
sures ;  and  the  end  in  view  certainly  justifies  what  at 
fii'st  sight  appears  to  be  a  harsh  practice. 

Although  carcinoma  may  progress  slowly,  it  none 
the  less  destroys  life  eventually  if  it  be  allowed  to 
pursue  its  course  uninfluenced  by  operation,  the  aver- 
age duration  of  life  from  the  first  observation  of  the 
disease  until  the  fatal  tennination  being  only  twenty- 
seven  months.  Even  when  subjected  to  the  knife 
the  reproductions  in  or  near  the  cicatrix,  in  the  lym- 
phatic glands,  or  in  the  viscera,  were  formerly  so 
invariable  as  to  lead  some  surgeons  to  refrain  from 
operating  under  any  circumstances.  Others,  influ- 
enced mainly  by  the  statistics  of  Paget,  Sibley,  and 
Baker,  advise  interference  mth  the  view  to  avert 
mental  anxiety  and  physical  suffering,  and  to  pro- 
long life ;  but  they  do  not  entertain  the  most  remote 
idea  of  effecting  a  radical  cure.  These  opposed  and 
erroneous  practices  are  obviously  the  result  of  deduc- 
tions based  upon  operations  inadequate  for  the  entire 
removal  of  the  disease,  since  the  common  procedure 


222  TUMORS  OF  THE  MAMMARY  GLAND. 

is  to  circumscribe  tlie  nipple  and  a  portion  of  the 
skin  by  two  incisions,  to  dissect  the  gland  out  of  its 
bed  of  fat  down  to  the  pectoral  fascia,  to  remove 
any  enlarged  glands  which  were  perceptible  to  the 
touch  previous  to  the  operation  by  extending  the 
wound  upward  into  the  axilla,  and  to  bring  the  lips  of 
the  incisions  nicely  together.  Such  operations  were 
deemed  to  suffice ;  but  they  fall  far  short  of  thor- 
oughness, as  the  very  structures  are  left  untouched 
in  which  the  disease  spreads  and  recurs.  A  carcino- 
ma is  not  encapsuled,  as  are  the  other  mammary  neo- 
plasms, so  that  its  cells  invade  the  surrounding  and 
adjacent  fasciae,  muscles,  fat,  and  skin,  which  are  con- 
verted into  so  many  separate  centres  of  new  growth 
and  latent  zones  of  infection  that  are  not  always 
appreciable  by  the  naked  eye.  Hence  the  infected 
neighboring  tissues  and  lymphatic  glands  are  the  ob- 
stacles in  the  way  of  permanent  relief,  and  must  be 
completely  gotten  rid  of  before  the  disease  can  be 
eradicated. 

In  a  remarkable  paper,  entitled  "  The  Influence  of 
Inadecjuate  Operations  upon  the  Theory  of  Cancer," ' 
the  late  Mr.  Moore,  of  London,  in  1867,  enunciated 
certain  doctrines  which,  had  they  been  widely  circu- 
lated and  appreciated  at  their  full  value,  would  pos- 
sibly ere  this  have  demolished  the  antiquated  and 
utterly  false  teachings  as  to  the  incurability  of  carci- 
noma. In  this  paper  he  insists  that  not  only  the 
entire  mamma,  but  that  all  involved  adjoining  tex- 
tures, as  the  skin,  fat,  pectoral  muscle,  and  lymphatic 
glands,  must  be  extirpated ;  and  that,  in  conducting 
the  operation,  the  tumor  should  neither  be  cut  into 

•  Med.-Chir.  Trans.,  vol.  1,  p.  245. 


TREATMENT.  223 

nor  be  seen.  These  suggestions — and  their  wisdom 
has  been  coniiiTaed  by  histological  researches — appear 
to  have  been  accepted  in  Denmark,  Germany,  and 
Austria ;  and  the  result  of  their  practical  adoption  has 
been  the  demonstration  of  the  fact  that  tumors  pro- 
nounced to  be  carcinomatous  by  the  most  competent 
observers  are  amenable  to  treatment.  This  view  is 
now  rapidly  gaining  adherents  among  the  best  minds 
in  all  parts  of  the  world;  and  surgeons  are  begin- 
ning to  know  that  cancer  can  be  cured  by  thorough 
operations  if  it  be  attacked  before  it  has  disseminated 
itself  extensively  locally  or  has  tainted  the  general 
system. 

In  favor  of  this  modern  doctrine,  the  life  history 
of  the  affection  shows,  first,  that  it  is  primarily  a  local 
degeneration  of  the  mamma,  and  that  its  tendency  is 
to  advance  toward  the  surface  before  it  invades  the 
deej)er  structures,  the  lymphatic  glands,  and  the  vis- 
cera ;  and,  secondly,  that  local  infection  does  not  en- 
sue, on  an  average,  before  the  expiration  of  thirteen 
months,  the  skin  being  involved  in  fourteen  months, 
the  lymphatic  glands  in  fifteen  months,  the  walls  of 
the  chest  in  twenty-two  months,  and  the  viscera  in 
thirty-one  months.  Hence,  if  the  local  trouble  can  be 
gotten  rid  of  before  it  has  contaminated  the  adjacent 
and  distant  structures,  there  is  no  reason  why  the 
remedy  should  not  prove  to  be  as  final  as  it  is  for  the 
non-carcinomatous  neoplasms. 

The  decision  of  the  curability  of  cancer  is  not 
only  based  upon  the  study  of  its  general  pathology, 
but  is  confirmed  by  the  practical  test  of  the  results 
of  operations.  In  settling  this  all-important  ques- 
tion, it  is  necessary  at  the  outset  to  define  what  is 


224  TUMORS  OF  TEE  MAMMARY  GLAND. 

meant  by  tlie  term  cure.  As  I  have  pointed  out 
in  tlie  chapter  on  carcinoma,  metastatic  tumors  de- 
velop in  thirty-one  months,  and  death  usually  ensues, 
no  matter  whether  the  patients  have  been  operated 
upon  or  not,  in  thirty-three  months  on  an  average. 
Local  reproduction  after  removal  is  witnessed  in  less 
than  one  case  out  of  every  hundred  after  the  expira- 
tion of  three  years ;  so  that,  if  the  patient  survives 
three  years  after  the  last  operation  without  recur- 
rence, or  dies  of  some  intercurrent  malady  under  the 
same  circumstances,  I  assume  that  she  has  recovered. 
Although,  of  course,  each  case  will  have  to  be  dealt 
with  in  accordance  mth  its  individual  merits,  the 
question  must  be  decided  by  facts  based  upon  the 
general  life  of  the  disease.  Of  485  cases  of  ordinary 
scirrhous,  medullary,  colloid,  and  atrophying  carcino- 
ma, in  which  the  history  is  complete,  51,  or  10*51  per 
cent. — and  47  were  still  living — fulfilled  these  re- 
quirements, the  average  life  after  operation  having 
been  four  years  and  ten  months.  Of  the  cases  in 
which  the  affection  pursued  a  natural  course  only  1*5 
per  cent,  survived  six  years ;  while  of  those  subjected 
to  the  knife  30  per  cent,  were  living  free  from  disease 
after  the  expiration  of  six  years,  and,  as  may  be  seen 
by  consulting  the  table  at  page  165,  four  were  alive 
for  more  than  seven  years,  and  the  remaining  eleven 
were  well  for  periods  which  varied  between  eight  and 
fifteen  years.  In  these  cases  it  is  not  at  all  probable 
that  the  disease  will  reappear,  so  that  they  must  be 
regarded  as  positive  recoveries  rather  than  as  exam- 
ples of  prolongation  of  life  after  operation. 

To  attain  this  long-sought-for  result  the  iiiles  laid 
down  by  Mr.  Moore  for  our  guidance  should  not  only 


TREATMENT.  225 

be  strictly  adhered  to,  but  they  should,  in  my  opin- 
ion, be  still  further  extended.  Thus,  in  the  most 
favorable  of  all  cases,  namely,  one  in  which  the  tumor 
is  of  moderate  volume,  and  devoid  of  superficial  and 
deep  attachments  and  enlargement  of  the  axillary 
glands,  the  proper  procedure  is  to  remove  the  entire 
breast  and  its  coverings  by  a  circular  incision,  search 
for  any  outlying  lobules  that  may  be  disseminated 
throughout  the  mammary  region,  dissect  off  the  fascia 
of  the  pectoral  muscle,  and  prolong  the  outer  portion 
of  the  incision  into  the  axilla  with  a  view  to  its  thor- 
ough exploration.  Although  the  glands  may  have 
eluded  detection  previous  to  surgical  interference,  care- 
ful examination  will  usually  disclose  that  several  are 
already  converted  into  secondary  tumors,  and,  in  this 
event,  the  axillary  space  must  be  thoroughly  cleaned 
out,  with  the  object  of  getting  rid  of  so  many  inde- 
pendent sources  of  infection  of  the  adjacent  tissues 
and  the  associated  glands.  Ample  experience  shows, 
first,  that  the  seats  of  recurrence,  or  rather  further 
spread  of  the  disease,  after  operation,  are  the  skin, 
paramammary  fat,  remains  of  the  mamma,  and  glands 
of  the  axilla ;  and,  secondly,  that  recurrence  in  the 
axilla  is  far  more  frequent  after  removal  of  the  breast 
alone  than  when  that  ca"\dty  was  freed  of  its  con- 
tents simultaneously  vai\\  the  extirpation  of  the 
breast.  Even  if  I  should  be  deemed  too  bold  in  rec- 
ommending that  the  axilla  be  attacked,  when  it  is 
apparently  free  from  disease,  surgeons  of  extended 
experience  will  certainly  agree  with  me  in  regarding 
the  adipose  tissue  as  being  largely  infiltrated  by 
young  cells,  for  it  is  just  precisely  in  corpulent  sub- 
jects that  local  reproduction  is  most  marked  along 
15 


226  TUMORS  OF  THE  MAMMARY  GLAND. 

tlie  line  of  tlie  cicatrix  of  partial  operations,  or,  in 
otlier  words,  in  tlie  fat  wMch  tliey  have  been  too 
anxious  to  save  in  order  that  they  might  secure  thick 
and  seemly  flaps. 

The  case  which  I  have  just  considered  is  one  in 
which  the  skin  and  pectoral  fascia  and  muscles  and 
glands  are  apparently  free  from  invasion.  Under 
opposite  circumstances  interference  is  by  no  means 
contraindicated,  provided  the  evidences  of  local  dis- 
semination are  not  extensive.  Thus,  out  of  48  of  the 
51  cures  in  which  the  extent  of  the  operation  is  noted, 
in  19  the  entire  breast  was  amputated  and  the  axilla 
was  cleaned  out ;  and  in  several  of  these  there  were 
nodules  in  the  skin,  and  the  upper  layer  of  the  great 
pectoral  muscle  was  removed.  It  is,  moreover,  com- 
forting to  know  that  the  glands  may  be  merely  the 
seat  of  irritative  hyperplasia,  since  in  three  cases  in 
which  they  were  permitted  to  remain  the  patients 
were  fi*ee  from  recurrence,  respectively,  for  five  years 
and  nine  months,  six  years  and  one  month,  and  ten 
years  and  ten  months.  Glandular  involvement  is, 
however,  of  bad  prognostic  import,  as  the  chances  for 
permanent  recoveiy  are  three  times  greater  when  the 
breast  alone  requires  amputation.  The  same  state- 
ment is  true  of  extensive  infiltration  of  the  pectoral 
muscles,  but  these  may  be  cut  away  ^\dth  a  free  hand 
with  some  prospect  of  a  successful  issue. 

When  the  axillary  glands  constitute  a  densely 
hard  and  knobby  tumor,  which  is  possibly  attached 
to  the  skin  and  the  side  of  the  chest,  and  the  corre- 
sponding arm  is  swollen,  the  probability  is  that  the 
loose  connective  tissue  and  fat  of  that  space  are  infil- 
trated, as  under  these  circumstances  the  glandular 


TREA  TMENT.  227 

growtli  bears  tlie  same  relation  to  the  adjacent  struc- 
tures as  does  tlie  mammary  neoplasm  to  its  surround- 
ings. Hence  in  cases  of  this  description,  it  is  far 
wiser  to  attack  the  axillaiy  tumor  before  the  primary 
gro^vth  is  interfered  with,  since,  if  the  former  cannot 
be  entirely  removed,  in  consequence  of  its  intimate 
connection  with  the  great  vessels  and  nerves  and  its 
extension  under  the  clavicle  into  the  neck,  it  will  be 
useless  to  proceed  with  the  operation. 

As  precautions  against  recurrence  the  exposed 
surfaces  may  be  sponged  with  a  strong  solution  of 
chloride  of  zinc,  or  be  seared  with  the  hot  iron ;  and 
the  latter  agent  should  always  be  employed  if  nod- 
ules have  been  cut  out  of  the  pectoral  or  intercostal 
muscles  or  the  ribs. 

While  I  am  not  unmindful  of  the  fact  that  these 
radical  measures  must  of  necessity  increase  the  mor- 
tality, I  cannot  avoid  thinking  that  the  end  justifies 
the  means.  The  older  and  more  simple  operation 
was  probably  fatal  in  about  one  case  in  fifteen,  al- 
though I  myself  have  lost  only  one  patient  out  of 
fifty-five  whom  I  subjected  to  partial  procedures. 
Within  the  past  seven  months,  however,  I  have 
adopted  the  principles  which  I  have  just  enunciated, 
that  is  to  say,  I  removed  the  mamma  and  its  coverings 
bodily,  dissected  off  the  pectoral  fascia,  and  cleaned 
out  the  axilla  in  five  cases,  and  all  recovered.  In 
favor  of  the  method  it  may  be  said  that,  as  the 
wound  is  an  open  one,  there  is  no  danger  of  the  reten- 
tion of  discharges  and  of  the  evil  consequences  which 
follow  that  accident.  That  the  mortality  is  not  ex- 
cessive is  sho^^Ti  by  the  statistics  of  adequate  opera- 
tions perfonned  at  the  Bethany  Hospital,  of  Berlin, 


228  TUMORS  OF  THE  MAMMARY  GLAND. 

from  1873  to  1876,  and  analyzed  by  Dr.  Stettegast;' 
and  by  the  statements  of  Henry  and  Winiwarter. 
Thus,  of  394  cases,  71,  or  18'02  per  cent.,  were  fatal; 
and  the  mortality  was  two-thirds  less  when  the  axil- 
lary glands  did  not  require  removal.  Thus,  of  264  in 
which  the  breast  was  amputated  bodily  and  the  axilla 
was  cleaned  out,  61, or  23*10  per  cent., died;  while  of 
130,  in  which  the  breast  alone  was  removed,  10,  or 
7'69  per  cent.,  were  fatal.  These  results  are  far  more 
favorable  than  those  obtained,  for  example,  from  the 
amputation  of  limbs  for  sarcoma  of  the  bones  or  even 
of  the  soft  parts ;  and  yet  the  veiy  surgeons  who  do 
not  hesitate,  and  I  speak  from  observation,  to  ampu- 
tate for  malignant  disease,  appear  to  be  un^\dlling  to 
incur  a  risk  in  the  attempt  to  eradicate  an  aifection 
which  is  so  surely  lethal  as  carcinoma  of  the  mamma. 
The  organ  itself,  even  if  it  were  sound,  is  no  longer 
of  any  use,  except  perhaps  for  the  preservation  of  a 
symmetrical  figure,  at  the  advanced  age  at  which 
cancer  develops,  and  on  this  gi'ound  there  can  be  no 
objection  to  its  removal.  Conservatism  in  the  use  of 
the  knife  cannot,  therefore,  in  the  light  of  modem 
pathological  investigations,  and  of  the  results  ob- 
tained from  adequate  operations,  which  are  based 
upon  these  researches,  be  too  strongly  condemned,  as 
it  not  only  deprives  women  of  their  only  chance  for 
a  permanent  recovery,  but  maintains  the  ojiprobrium 
which  has  for  centuries  adhered  to  operations  for  this 
class  of  affections. 

For  the  disrepute  into  w^hich  operations  have 
fallen  sm'geons  are  not  alone  responsible.  Many  pa- 
tients are  averse  to  the  knife  at  the  veiy  time  when 

'  Langcnbeclc'a  Archiv,  Ed.  sxiv,  1879,  p.  62a. 


TREATMENT,  229 

it  holds  fortli  tlie  best  prospects  for  success ;  and  not 
a  few  family  attendants,  who  are  consulted  when  the 
case  is  amenable  to  treatment,  are  in  the  habit  of 
waiting  for  further  manifestations  before  they  seek 
surgical  assistance.  By  such  a  course,  which  is  in 
the  highest  degree  reprehensible,  not  only  is  injustice 
done  to  all  concerned,  but  many  lives  are  sacrificed 
which  might  have  been  spared  had  the  woman  been 
seen  when  the  malady  was  in  its  incipiency.  Hence 
physicians  should  know  that  a  hard  tumor  of  the 
mamma  after  the  age  of  forty  is  most  suspicious,  since 
the  chances  are  as  thirteen  to  one  in  favor  of  its  be- 
ing of  a  carcinomatous  nature ;  and  their  doubts  may 
give  way  to  comparative  certainty  if  there  is  a  history 
of  heredity,  if  the  growth  started  from  an  induration 
consequent  upon  puei'peral  mastitis,  or  if  there  is  an 
obstinate  psoriasis  or  eczema  of  the  nipple.  Under 
these  circumstances  the  surgeon  should  not  hesitate 
to  sacrifice  the  entire  organ. 

The  probability  of  recurrence  after  thorough  oper- 
ations is  so  greatly  diminished  that  local  reproduc- 
tion was  mtnessed  in  only  5  of  the  51  patients  who 
recovered  permanently.  In  three  there  was  one  re- 
currence ;  while,  in  one,  there  were  two  recurrences 
in  a  twelvemonth,  and  in  one  there  were  three  repro- 
ductions in  four  years.  In  these  two  cases  the  sub- 
jects were  perfectly  well,  respectively,  for  four  and  a 
half  and  for  twelve  years  after  the  last  operation ;  so 
that,  as  in  the  case  of  sarcoma,  recurrent  tumors 
should  be  freely  extii'pated  as  fast  as  they  appear. 

There  are  of  course  certain  cases  in  which  the 
disease  has  advanced  so  far  that  operations  are  not 
justifiable.     Thus,  in  chronic  atrophying  scirrhus,  a 


230  TUMORS  OF  THE  MAMMARY  GLAND. 

variety  of  carcinoma  in  wliich  the  surrounding  tissues 
are  always  extensively  infiltrated,  and  in  wliich,  more- 
over, tlie  patient  may  live  for  many  years  in  compara- 
tive comfort,  the  knife  sliould  be  mtliheld :  nor  sliould 
the  suro;eon  interfere  wlien  there  are  si2:ns  of  visceral 
contamination ;  wlien  tlie  attachments  involve  the  en- 
tire mammary  region ;  when  both  breasts  are  exten- 
sively affected ;  wlien  the  skin  of  tlie  opposite  side 
contains  nodules ;  or  wlien  tlie  glands  of  tlie  axilla 
are  intimately  connected  witli  tlie  vessels  and  nerves, 
as  denoted  by  their  immobility,  by  pain  and  tumefac- 
tion of  tbe  coiTesponding  aim,  and  by  oedema  of  the 
breast,  and  the  more  especially  if  tlie  glands  of  tlie 
neck  be  simultaneously  contaminated. 

In  speaking  of  removal  I  have  made  mention  of 
no  measures  except  tlie  knife,  simply  because  I  be- 
lieve that  what  cannot  be  reached  by  the  scalpel  can- 
not be  reached  by  caustic  applications.  While  the 
latter  are  so  uncertain  in  their  action  that  rapid  recur- 
rence may  be  anticipated,  I  do  not  think  that  they 
are  to  be  entirely  condemned ;  but  I  would  restrict 
their  employment  to  the  allaying  of  fetor  and  the  im- 
provement of  the  surface  of  open  cancers.  In  cases 
of  this  description  Esmarch '  employs  a  powder  com- 
posed of  arsenic  acid  and  muriate  of  morphia,  of  each, 
0'25,  calomel  2*0,  and  powdered  gum  arabic  12*0,  of 
which  he  sprinkles  half  a  teaspoonful  daily  on  the 
surface  until  a  yellomsh  and  leathery  crust  forms, 
which,  on  dro23ping  off,  leaves  a  clean  granulating  sur- 
face. He  not  only  states  that  this  application  is  safe, 
painless,  and  disinfecting,  but  illustrates  its  action  by 
drawings  of  a  case  of  medullary  carcinoma  in  which 

'  Langenbcck' s  Archiv,  Ed.  xsii,  p.  449. 


i 


TBEAMTENT.  231 

its  good  effects  are  most  striking.  The  paste  of  clilo- 
ride  of  zinc,  whicli  is  usually  employed,  is  so  exces- 
sively painful  tliat  its  application  cannot  be  recom- 
mended. 

Altliougli  parencliymatous  injections  of  acetic  acid 
and  other  fluids,  electropuncture,  compression,  and 
congelation  have  apparently  retarded  the  j^rogress  of 
cancer,  I  am  of  the  opinion  that  their  employment  is 
merely  a  waste  of  time. 

When  oj)erative  interference  is  inappropriate,  all 
that  can  be  done  is  to  render  life  endurable  by  the 
relief  of  pain,  the  arrest  of  hemorrhage,  and  the  cor- 
rection of  fetor. 

To  fulfil  the  first  of  these  indications,  if  the  suf- 
fering be  great,  the  patient  should  be  kept  gently 
and  continuously  under  the  influence  of  opium  or 
some  of  its  preparations,  hypodermic  injections  of 
morphia  with  a  minute  quantity  of  atropia  being  the 
most  generally  applicable.  If  the  pain  is  increased  by 
the  active  growth  of  the  neoj)lasm,  I  know  of  nothing 
that  mitigates  it  so  rapidly  as  the  local  application  of 
acetate  of  lead  in  the  proportion  of  fifteen  grains  to 
the  ounce  of  water.  Under  similar  circumstances,  or 
when  the  breast  is  hot,  tense,  tender,  and  perhaps 
throbbing,  bags  of  ice  afford  great  relief.  AVhen  the 
active  symptoms  have  subsided,  these  measures  may 
give  way  to  an  application  composed  of  a  drachm 
each  of  the  extract  of  belladonna  and  the  extract  of 
stramonium  to  the  ounce  of  ointment  of  petroleum  or 
cosmoline.  Should  the  corresponding  arm  be  oedem- 
atous  and  painful,  it  should  be  enveloped  in  a  flan- 
nel roller  and  kept  elevated  on  a  pillow. 

In  the  event  of  hemorrhage  resisting  cold  and  the 


232  TUMORS  OF  THE  MAMMARY  GLAND. 

ordinary  astringent  applications,  it  may  be  cliecked 
by  pressing  a  bit  of  hemostatic  cotton,  wliicli  is  j^re- 
pared  by  soaking  absorbent  cotton  in  Monsel's  solu- 
tion and  permitting  it  to  diy,  directly  upon  the  bleed- 
ing orifice.  As  a  deodorizer  five  grains  of  chloral 
hydrate  to  the  ounce  of  cosmoline,  an  application 
which  also  possesses  the  merit  of  assuaging  pain,  Avill 
be  found  most  useful.  When  the  tumor  is  sloua-hins: 
it  should  be  covered  with  an  elm  poultice  medicated 
with  balsam  of  Peru,  or  a  weak  solution  of  chloral, 
permanganate  of  potassa,  chloralum,  chlorinate  of 
soda,  girondin,  or  chloride  of  zinc.  When  the  dead 
parts  have  separated,  the  ointment  of  chloral  is  my 
favorite  remedy. 

Under  all  circumstances  the  breast  must  be  pro- 
tected from  friction,  injurious  comj)ression,  and  the 
risk  of  blows,  and  changes  of  temperature.  Hence 
the  patient  should  be  requested  to  lay  aside  her  cor- 
set, and  cover  the  organ  with  a  piece  of  spongio- 
piline,  a  rabbit  skin,  or  a  layer  of  cotton  wool,  con- 
fined by  a  roller  or  handkerchief.  If  the  tumor  be 
open,  oiled  silk  or  paper  should  be  placed  between 
the  dressings  and  the  outer  coverings  to  ensure  clean- 
liness. 

With  regard  to  general  measures  it  need  only  be 
stated  that  the  diet  should  be  light,  nutritious,  and 
assimilable,  and  that  the  strength  should  be  supported 
by  tonics,  of  which  the  best  are  the  tincture  of  the 
chloride  of  iron,  tincture  of  nux  vomica  or  stiychnia, 
and  quinine. 

In  the  removal  of  the  entire  breast  the  anaesthe- 
tized patient  should  be  placed  recumbent,  with  the  af- 


TREATMENT.  233 

fected  side  sliglitly  elevated,  and  tlie  ann  lield  off  at 
a  right  angle  to  tlie  body.  A  large  and  stout  scalpel 
is  then  thrust  directly  down  through  the  skin  and  fat 
to  the  aponeurosis  of  the  great  pectoral  muscle,  and 
carried  around  the  organ,  so  as  to  encircle  it.  If  the 
mass  be  attached  to  the  pectoral  fascia,  the  latter 
structm*e  should  be  dissected  off  with  it,  the  assist- 
ants being  on  the  alert  to  compress  with  their  fingers, 
or  with  the  small  arteiy  forceps  of  Nunneley,  the  ori- 
fices of  divided  vessels,  which  should  be  successively 
ligated  when  the  amputation  is  completed.  The  next 
care  of  the  surgeon  should  be  to  search  for  and  remove 
any  outlying  lobules  of  the  gland,  his  attention  being 
esj^ecially  du-ected  toward  the  axillaiy  border  of  the 
incision,  where  they  are  generally  to  be  found.  He 
should  then  examine  carefully  the  muscles  of  the 
walls  of  the  chest  and  the  costal  cartilages,  and  fi^eely 
extii'pate  any  nodules  which  may  be  situated  in  these 
stnictures,  and  afterward  cauterize  the  wounds  with 
the  ordinaiy  or  ^vith  Paquelin's  cautery.  These 
points  having  been  attended  to,  he  should  next  carry 
his  index  finger  along  the  lower  prominent  border  of 
the  pectoral  muscle  and  penetrate  the  axilla,  which  he 
should  thoroughly  clean  out  if  he  discovers  that  any 
glands  be  enlarged.  In  executing  this  step  of  the 
operation,  an  incision  is  to  be  prolonged  into  that 
space  through  the  skin  and  fascia,  after  which  the 
knife  is  to  be  laid  aside,  and  the  diseased  structures  are 
to  be  removed  mth  the  fingers,  assisted,  if  it  be  neces- 
sary, by  closed  scissors  curved  on  the  flat,  or  ■\\dth  peri- 
osteal elevators.  The  practice  of  drawing  do\^Ti  the 
indurated  and  attached  glands  with  a  tenaculum  or 
double  hook  renders  the  large  vessels  very  liable  to 


234  TUMORS  OF  TEE  MAMMARY  GLAKD. 

injuiy,  wliicli  exposes  the  patient  to  the  dangers  of 
hemorrhage  and  the  entrance  of  air.  Hence  it  is  more 
prudent  to  trust  to  the  fingers  alone,  without  making 
traction  on  the  axillary  growth.  Should  any  vessels 
be  opened,  they  must  be  ligated  forthwith.  Care  must 
be  taken  also  to  cany  the  fingers  under  the  j)ectoral 
muscles,  as  diseased  stiTictures  are  not  infrequently  to 
be  found  in  that  locality.  Conducted  in  this  way,  the 
operation  is  most  simple,  and  I  have  more  than  once 
performed  it  without  having  to  ligate  a  single  vessel 
in  the  axillary  space. 

Hemorrhage  having  been  restrained*  and  clots 
removed,  the  upper  portion  of  the  axillary  wound  is 
then  brought  together  with  a  few  interrupted  sutures, 
and  an  oiled  tent  inserted  into  its  lower  angle,  with 
the  view  of  affording  free  drainage.  The  large 
wound  resulting  from  the  extirpation  of  the  breast 
may  be  veiy  materially  diminished  by  dissecting  the 
skin  for  several  inches  from  its  deep  connections,  and 
by  inserting  several  sutures  at  a  considerable  dis- 
tance from  the  edges,  whereby  they  may  be  drawn 
nearer  together. 

The  entire  surface  is  then  protected  by  an  oiled 
compress  confined  by  adhesive  strips  and  a  broad 
roller,  through  the  latter  of  which  the  arm  is  also 
fixed  to  the  chest.  The  patient  is  put  to  bed,  and  a 
suitable  amount  of  moi'phia  is  thro"\vn  under  the  skin. 

I  have  myself  never  resorted  to  antiseptic  precau- 
tions in  amputating  the  mammary  gland.  The  wound 
being  an  open  one,  there  are  no  dangers  to  be  feared 
from  decomposing  retained  secretions  or  clots  of  blood, 

'  The  general  oozing  from  the  pectoral  muscle  can  readily  be  arrested  by 
cloths  wrung  out  of  hot  water. 


I 


TREATMENT.  235 

and  tlie  five  patients  that  I  subjected  to  tlie  proce- 
dure all  recovered  under  simple  dressings.  In  tlie 
partial  extirpations  of  tlie  breast  tliat  I  have  practised, 
I  have  also  restricted  myself  to  the  compress  of  oiled 
lint,  and  I  have  never  had  reason  to  regret  the  prac- 
tice. Whether  the  antiseptic  treatment  has  dimin- 
ished the  mortality  of  the  operations  upon  the  mam- 
mary gland,  it  is  impossible  to  say  from  any  very  ex- 
tended experience,  although  the  observations  of  Olde- 
kop  on  this  point  are  not  in  its  favor.  Thus  of  184 
operations  there  were  16  deaths,  or  in  the  ratio  of  8*7 
per  cent.,  under  ordinary  dressings;  while,  of  T7  con- 
ducted upon  the  antiseptic  principle,  7,  or  9-1  per 
cent.,  were  fatal. 

The  dressings  should  not,  unless  the  weather  be 
warm,  be  removed  before  the  expiration  of  three 
days,  when  an  elm  poultice  may  be  substituted  for  the 
oiled  lint,  and  the  tent  be  removed  from  the  axilla, 
the  wound  being  kept  open  subsequently  by  the  daily 
insertion  and  expansion  of  the  blades  of  the  dressing- 
forceps.  The  sutures  should  be  pemiitted  to  remain 
as  long  as  they  are  doing  good.  With  the  view  of 
promoting  the  granulating  process,  when  cicatrization 
is  well  established  the  surface  may  be  touched  daily 
with  a  weak  solution  of  nitrate  of  silver ;  or  healing 
may  be  expedited,  when  the  wound  is  very  large,  by 
epidemic  grafting. 

For  the  removal  of  the  innocent  small  neoplasms, 
it  suffices  to  grasp  them  between  the  fingers  of  one 
hand,  lay  open  their  capsule,  and  enucleate  them 
with  the  handle  of  the  scalpel  or  mth  the  index  fin- 
ger. When  the  skin  is  ulcerated,  it  should  be  in- 
cluded between  two  curvilinear  incisions :  and  under 


23G  TUMORS  OF  THE  MAMMARY  GLAND. 

all  circumstances  tlie  nipple  should,  if  possible,  be 
spared,  and  tlie  incision  be  carried  in  a  line  radiating 
from  it  toward  tlie  peripheiy  of  the  gland.  If  the 
growth  be  small,  union  by  the  first  intention  should 
be  aimed  at  by  accurate  apposition  of  the  edges  of 
the  wound  and  the  application  of  a  compress.  If,  on 
the  other  hand,  the  wound  be  a  large  one,  a  tent 
should  be  inserted  into  its  most  dependent  portion, 
or  at  its  lower  angle,  with  the  view  to  proper  drain- 
age, since,  if  primary  union  throughout  be  attempted, 
experience  shows  that  erysipelas,  septicaemia,  and  py- 
aemia are  of  not  infrequent  occurrence. 

The  treatment  of  cysts  does  not  differ  from  that 
of  similar  formations  in  other  organs.  Birkett '  states 
that  he  has  cured  eighteen  cases  of  cysts  with  serous 
contents  by  simple  puncture  and  by  an  embrocation 
consisting  of  hydrochlorate  of  ammonia,  alcohol,  and 
camphor  mixture.  Injection  of  iodine  or  other  irri- 
tating fluids,  or  the  insertion  of  a  delicate  seton,  some- 
times answers  a  good  purpose;  but  the  only  mea- 
sures worthy  of  confidence  in  the  management  of 
small  cysts  are  their  extii*pation,  or  laying  them  open 
and  packing  them  with  lint  to  excite  their  oblitera- 
tion by  granulations.  When  large  and  solitary,  their 
contents  may  be  let  out,  a  drainage-tube  be  inserted, 
and  gentle  compression  be  applied  to  favor  their  con- 
traction and  obliteration.  Hydatid  cysts  demand  free 
incision  and  dressing  from  the  bottom ;  while  multi- 
ple cysts  require  removal  of  the  entire  gland,  a  suf- 
ficiency of  integuments  being  preserved  to  admit  of 
accurate  closure  of  the  wound. 

'  Holmes's  System  of  Surgery,  2d  ed.,  vol.  v,  p.  266. 


I 


CHAPTEE    XIII. 

TUMORS  OF  THE  MALE  MAMMARY  GLAND. 

The  mamma  of  the  male  is  liable  to  the  same 
neoplastic  and  cystic  formations  as  are  met  with  in 
the  female ;  but  they  are,  for  obvious  reasons,  very 
uncommon. 

Of  the  neoplasms  derived  from  the  connective 
tissue  framework  of  the  organ,  Virchow  describes  a 
fibroma; '  while  Croft,"  Duplay,'and  Bourdillat*  have 
recorded  examples  of  spindle-celled  sarcoma;  and  I 
myself  have  examined  a  section  of  a  recurrent  growth 
of  that  nature  removed  by  Dr.  Dawson,  of  Cincinnati. 
Duplay,"  moreover,  refers  to  a  case  of  round-celled 
sarcoma  in  which  the  patient  was  free  from  recur- 
rence six  years  after  operation. 

Of  those  originating  in  the  glandular  structure, 
Obolensky"  met  with  a  myxomatous  adenoma,  and 
Wagstaffe'  and  Horteloup'  have  tabulated,  respec- 
tively, sixty-one  and  seventy  examples  of  carcinoma; 
but  they  have  included  in  their  tables  several  in- 
stances of  sarcoma.     Chenet '  and  Marcano  "  have  de- 

'  •  Op.  ciL,  t.  i,  p.  329. 
^  Trans.  Path.  Soc.  London,  vol.  xxvii,  p.  249. 
2  Op.  cit.,  t.  V,  p.  664. 
^  Bull,  de  la  Soc.  Anal.,  ser.  2,  t.  xi,  p.  94. 
5  Op.  cit.,  t.  V,  p.  664. 

®  Virchow-Hirscli's  Jahreshcricht,  Bd.  i,  p.  305. 
'  Trans.  Path.  Soc.  London,  vol.  xxvii,  p.  234. 
®  Tumeurs  du  Sein  chez  P Homme,  These  de  Paris,  18Y2. 
^  Virchow-Hirschh  Jahresbericht,  Bd.  ii,  ISVY,  p.  401. 
'"  Bull,  de  la  Soc.  Anat.,  t.  xlix,  p.  921. 


238      TUMOES  OF  THE  MALE  MAMMARY  GLAND. 

scribed  cases  of  melanotic  carcinoma ;  Lannelongue* 
and  Doutrelepont "  have  observed  disseminated  scir- 
rlius ;  Cooke  ^  describes  an  atropliying  carcinoma ;  and 
Oilier*  bas  met  witb  tbe  cuirass  form  of  the  affec- 
tion. Cruveilhier,  Vidal,  Berard,  Larrey,  Blandin, 
and  Desguise  have  described  encepbaloid  carcinoma ; 
but,  in  tbe  absence  of  careful  minute  examination, 
tbeir  true  nature  is  questionable. 

Sir  James  Paget '  believes  that  of  every  100  cases 
of  scirrhous  carcinoma  of  the  mamma  only  2  occur  in 
men.  Of  102  examples  of  which  I  have  a  record,  I 
have  seen  only  2  in  males,"  from  one  of  which  fig. 
16  was  taken,  Billroth '  out  of  252  cases  had  7 ; 
and  Henry '  out  of  196  examples  saw  4  in  men ;  so 
that  the  proportion  is  as  1  to  42. 

Of  the  cystic  formations  Velpeau "  describes  one 
containing  milk ;  while  he  met  mth  three  ordinary 
retention  cysts,"  of  which  examples  are  also  recorded 
by  Gowlland,"  Hoffmann,"  Roux,"  Broca,"and  Anger.'* 

As  the  development,  histoiy,  diagnosis,  and  treat- 
ment of  tumors  of  the  male  mammary  gland  do  not 
present  peculiar  features,  their  further  consideration 
need  not  detain  us. 

'  Ilorteloup,  op.  cif.,  p.  80. 

-  Revue  dcs  Sciences  Medicales  de  JIayem,  IST-l,  p.  2G5. 

'^  London  Lancet,  vol.  ii,  1859,  p.  462. 

"•  Ilorteloup,  op.  cit.,  p.  82. 

5  Op.  cit.,  p.  634. 

«  Fhila.  Med.  Times,  July  5,  IS19,  p.  484. 

'•  Chir.  Klinik,  Wicn,  lS71-'76,  p.  269. 

8  Op.  cit,  p.  121. 

^  Ilorteloup,  op.  cit.,  p.  49. 

'0  Ibid. 

11  London  Lancet,  vol.  ii,  1861,  p.  498. 

'2  Klebs,  op.  a7.,  p.  1199. 

"  Ilorteloup,  op.  cit.,  p.  50. 

"iiif/.,  p.  51.  ^^Ibid.f^.  51. 


I  ]:^  D  E  X. 


PAGE 

Acetic  acid,   injection  of,  in  carci- 
noma     231 

Acinous  adenoma 114 

carcinoma 132 

Adenocele 3,  110 

cystic 38 

cystoid 38 

Adenoflbroma 49 

Adenoid  sarcoma 71,  57 

Adenoid  tumor,  relation  of,  to  carci- 
noma      23 

Adenoma 3,  110 

acinous 114 

atypical 113 

complications  of 122 

cystic 113,  116,  118 

cystoid 38 

degenerations  of 118 

diagnosis  of 123,  213 

etiology  of 120 

general  pathology  of J  20 

gross  features  of 119 

growth  of 121 

in  male 237 

minute  features  of. Ill 

myxomatous 118 

prognosis  of 122 

recurrence  of 122 

starting-point  of  carcinoma 23 

synonymes  of. 110 

telangiectatic 118 

treatment  of 220 

tubular 112,  116 

typical Ill 

ulceration  of. 122 


PAGE 

Adenoma,  vegetating 118 

Age,  relation  of,  to  carcinoma.  26,  33, 142 
relation  of,  to  non-carcinoma- 

tous  growths 26 

Albuminous  carcinoma 69 

Alveolar  sarcoma 68 

Amputation  of  breast 232 

Amy  clinic  neuroma 10,  61 

Antiseptic  dressing  after  operations.  234 

Arsenic  in  treatment  of  carcinoma. .  230 

Atrophying  scirrhus 131 

diagnosis  of 214 

general  pathology  of 179 

gross  features  of 139 

in  the  male 238 

minute  features  of 131 

prognosis  of 181 

radical  cure  of 181 

Axillary     glands,     see     Lymphatic 

glands. 

Benign  connective  tissue  neoplasms.  9 

Breast,  amputation  of 232 

development  of IS 

elephantiasis  of 47 

general  hypertrophy  of 47 

partial  excision  of. 221 

Cachexia,  cancerous 162 

Calcifying  carcinoma 137 

fibroma 53 

mvolution  cysts 188 

lacteal  cysts 191 

sarcoma 78 

Cancer,  see  Carcinoma. 


240 


INDEX. 


PAGE 

Cancer  cells 125 

en  cuirasse 151 

in  male 238 

Cancerous  cachexia 162 

Carcinoma 124 

acinous 132 

aflBnities  and  contrasts  of 182 

age  in  relation  to 26,  33, 142 

atrophying 131 

calcifying 137 

caseation  of 141 

cells  of 125 

colloid 135 

connective  tissue 130 

connective  tissue,  origin  of 13 

contraindications  to  operations 

for 229 

course  of 144 

cystic 136 

cystoid 141 

definition  of 124 

degenerations  of 141 

development  of 13,  19,  23,  126 

diagnosis  of 169,  198,  213 

duration  of  life  in 163 

eczema  of  nipple  in  relation  to.     28 

elevation  of  temperature  in .  26, 142 

encephaloid 132 

epithelial  origin  of 14 

etiology  of 142 

extension  of 128 

fasciculated 09 

fatty  degeneration  of 141 

fibrous 130 

fixation  to  chest  of 154 

gelatinous 135 

gross  features  of 138 

growth  of 145 

hard 130 

hereditability  of 27 

histogenesis  of 13,  19,  23,  126 

hydatides 38 

infection  of  contiguous  tissues 

in 148 

infection  of  lymph  glands  in. . .   156 

infection  of  skin  in 149 

inflammation  of 142 

lipomatous   138 

local  nature  of 27,  223 

lymphatic  glands  in 156 


P.4.GE 

Carcinoma,  mastitis  in  relation  to  . .     31 

medullary 132 

melanotic 136 

metastasis  of 159 

multicellular 132 

myxomatous 137 

of  male  mamma 237 

pain  in 148 

pigmented 136 

prognosis  of 163,  169 

psoriasis  of  nipple  in  relation  to    28 

radical  cure  of 164 

recurrence  of,  after  removal 166 

retraction  of  nipple  in 147 

sarcomatous 134 

scirrhous 130 

seat  of 145 

sexual  activity  in  relation  to. . .     26 

simple 131 

social  state  in  relation  to 26 

soft 132 

stroma  of 125 

structure  of 124 

suppuration  of 142 

telangiectatic 134 

transformations  of 141 

trauma  in  relation  to 26 

treatment  of 224 

tuberous 132 

tubular 130 

ulceration  of 152 

varieties  of 129 

varieties  of,  frequency  of 140 

villous 137 

Carcinomatous  epithelioma 124 

Carcinomatous  tumors,  diagnosis  of.  198 
Caustics  in  treatment  of  carcinoma. .  230 

Chloral  hydrate  as  a  deodorizer 232 

Chloride  of  zinc  in  treatment  of  car- 
cinoma     220 

Chondroma 10 

Classification  of  cysts 7 

of  neoplasms 6 

of  tumors 1 

Coexistence  of  epithelial  and  connec- 
tive tissue  tumors 24 

Colloid  carcinoma 135 

diagnosis  of 214 

diagnosis  of,  fro.ni  my.xoma... .   176 

general  pathology  of 174 


INDEX. 


241 


PAGE 

Colloid  carcinoma,  gross  features  of.  139 

minute  structure  of 135 

prognosis  of 175 

radical  cure  of 176 

Colloid  tumor 101 

Compression  in  treatment  of  tumors  217 
Congelation  in  treatment  of  carci- 
noma    231 

Connective  tissue  neoplasms 36 

anatomy  of 36 

atypical 7 

benign 9 

circumscribed 47 

classification  of 6 

cystic 37 

development  of 43 

diffused 47 

malignant 9 

solid  .- 38 

recurrent 9 

typical  - 7 

vegetating 36 

Connective   tissue  origin  of   carci- 
noma      13 

Corps  fibreux 49 

Cuirass  form  of  carcinoma 157 

in  male 238 

Curability  of  carcinoma 223 

Cystic  adenoceles 38,  50 

Cystic  adenoma 3S,  50,  113,  116,  118 

Cystic  carcinoma 136 

gi-oss  features  of 140 

minute  features  of 136 

Cystic  connective  tissue  neoplasms..    38 

Cystic  fibroma 39,  50 

diagnosis  of 63 

growth  of 57 

Cystic   non-carcinomatous    tumors, 

diagnosis  of 208 

Cystic  sarcoma 72,  81 

diagnosis  of 99 

Cystoid  adenoceles 38 

adenoma 38,  50 

carcinoma 141 

fibroma 53 

myxoma 103 

sarcoma 72,  77 

Cystoide  drusengcschwlilstc 38 

Cystosarcoma 38 

Cystosarcoma  fibrosum 50 

IG 


PAGE 

Cystosarcoma  mucosum 101 

Cysts 1,  183 

classification  of 7,  183 

dermoid 134 

duct 39,  184 

evolution 133 

follicular 43 

hydatid 194 

involution 185 

lacteal 191 

multiple 186 

proliferous  mammary 38 

relative  frequency  of 9 

retention 1S4 

retrograde 37 

sebaceous  .  .• 184 

simple 184 

single 186 

treatment  of 236 

Dermoid  cysts 184 

Development  of  breast 13 

of  neoplasms 13 

Diagnosis   of  tumors   of  mammary 

gland 197 

of  carcinomatous  tumors 193 

of  cystic  tumors 208 

of  non-carcinomatous  tumors. .  198 

of  solid  tumors 208 

Disseminated  scirrhus. .    151 

in  male 238 

Duct  cysts 39,  184 

Echinococcus  cysts 194 

Eczema  of  nifiple,  relation  of,  to  car- 
cinoma    28,  144 

to  non-carcinomatous  growths .     31 

Electropuncture  in  treatment  of  car- 
cinoma    231 

Elephantiasis  of  breast 47 

Embryoplastic  tumor 66 

Encephaloid  carcinoma,  see  Medul- 
lary carcinoma. 

Encephaloid  sarcoma 66 

Endocanalicular  tumors 39 

Epithelial  infection 15 

Epithelial  neoplasms 7 

atypical 7 

classification  of 7 

development  of 21 


242 


INDEX. 


Epithelial  neoplasms,  malignant ...  9 

recurrent 9 

typical 7 

Epithelial  origin  of  carcinoma 14 

Epithelioma 115 

carcinomatous 124 

Etiology  of  neoplasms 25 

Evolution  cysts 188 

development  of 188 

diagnosis  of 190,  214 

general  pathology  of 188 

inflammation  of 190 

treatment  of 236 

ulceration  of 190 

Evolution  of  neoplasms 12 


Fasciculated  carcinoma 

sarcoma 

Fibroma  

calcifying   

complications  of 

cystic 

cystoid 

degenerations  of 

diagnosis  of. 

endocanaliculaire 

general  pathology  of . . . . 

gross  features  of 

growth  of 

inflammation  of 

intracanalicular 

lipomatous  

minute  features  of 

my.xomatous 

of  male  mamma 

ossifying 

prognosis  of 

recurrence  of 

relation  of,  to  carcinoma . 

synonymes  of 

telangiectatic 

treatment  of 

Fibronucleatcd  tumor 

Fibroplastic  tumor 

Fibrous  carcinoma 

Follicular  cysts 

Fungating  adenoma 

fibroma 

myxoma 

sarcoma 


39 


63, 


69 

69 

49 

53 

59 

,  50 

53 

53 

211 

50 

54 

50 

56 

52 

40 

53 

50 

53 

237 

53 

62 

61 

23 

49 

53 

218 

69 

69 

130 

43 

122 

52 

105 

76 


PAGE 

Fungus  hcmatodes 134 

Galactocele,  see  Lacteal  cysts. 
Gelatinous    carcinoma,  see    Colloid 

carcinoma. 

Gelatinous  sarcoma 101 

tumor 101 

General  hypertrophy  of  the  breast. .     47 

Giant-celled  sarcoma 70 

Glands,  lymphatic,   see  Lymphatic 

glands. 

Granulation  sarcoma 66 

Growth  of  neoplasms 21 

Hard  carcinoma,  see  Scirrhous  carci- 
noma. 

Hereditability  of  carcinoma 27 

of  non-carcinomalous  growths.  23 

Hydatid  cysts 194 

anatomy  of. 195 

development  of 194 

diagnosis  of 196,  215 

frequency  of. 194 

general  pathology  of 195 

prognosis  of 196 

treatment  of. 236 

Hypertrophic  partielle 110 

Inflamed  adenoma 122 

carcinoma 142 

evolution  cysts 190 

fibroma 52 

my.xoma 105 

sarcoma 76 

Injury,  relation  of,  to  carcinoma 26 

to  non-carcinomatous  growths.     26 

Intracanalicular  tumors 39 

Involution  cysts 185 

development  of 185 

diagnosis  of 187,  214 

general  pathology  of 186 

prognosis  of 187 

treatment  of 236 

Irritable  tumor 60 

Lacteal  cysts 191 

contents  of 191 

development  of 191 

diagnosis  of 193,  214 


INDEX. 


243 


PAGE 

Lacteal  cysts,  general  pathology  of.  192 

liquid 191 

of  male  mamma 238 

solid 191 

treatment  of 23G 

Lipoma *. . .     10 

development  of 20 

Lipomatous  carcinoma 138 

fibroma 53 

myxoma 103 

sarcoma 77 

Local  nature  of  carcinoma 27,  223 

Lymph  spaces,  relation  of,  to  carci- 
noma      17 

Lymphatic  glands,  enlargement  of, 

in  adenoma 122 

enlargement  of,  in  cysts 187 

enlargement  of,  in  myxoma 108 

enlargement  of,  in  sarcoma 8G 

extirpation  of. , 233 

infection  of,  in  carcinoma 15G 

infection     of,    as     influencing 

life 158,226 

infection  of,  as  influencing  me- 
tastasis    159 

infection  of,  as  influencing  op- 
eration   158 

infection  of,  as  influencing  re- 
currence    1G8 

Lymphoid  sarcoma 67 

Malignant   connective    tissue    neo- 
plasms   9 

Mammaiy  gland  of  the  male,   tu 

mors  of 237 

Mammary  glandular  tumor 38, 110 

Mastitis,   puerperal,   relation  of,  to 

neoplasms 31 

Medullary  carcinoma 132 

diagnosis  of 213 

diagnosis   of,  from   medullary 

sarcoma 173 

encysted 137 

general  pathology  of 171 

gross  features  of 139 

minute  features  of 132 

prognosis  of 172 

radical  cure  of 173 

Medullary  sarcoma 66 

diagnosis  of 212 


PAGE 

Medullary    sarcoma,    diagnosis    of, 

from  medullary  carcinoma. . .  173 

Melanotic  carcinoma 136 

of  male  mamma 238 

Melanotic  sarcoma 73 

Metastasis  of  carcinoma 159 

of  myxoma 107 

of  sarcoma 94 

Mucous  tumor 101 

Multicellular  carcinoma 132 

Myeloid  sarcoma 70 

Myxoma 101 

complications  of. 107 

cystoid 103 

diagnosis  of lOS,  212 

diagnosis  of,  from  colloid  carci- 
noma   176 

fibrous 103 

fungating 105 

general  pathology  of 105 

gross  features  of 101 

growth  of 105 

histogenesis  of 19,  104 

hyaline 101 

inflammation  of 105 

lipomatous 103 

medullary 102 

metastasis  of 107 

minute  features  of 101 

paramammary 103 

prognosis  of 1 07 

reciurence  of 10" 

telangiectatic 103 

treatment  of. 219 

varieties  of 102 

Myxomatous  adenoma 118 

of  male  mamma 237 

Myxomatous  carcinoma 137 

fibroma 53 

sarcoma 77 

Neoplasms,  atypical 7 

benign 8 

classification  of 6 

connective  tissue 6,  36 

degenerations  of 22 

development  of 12 

diseases  of 22 

epithelial 7 

etiology  of 25 


244 


INDEX. 


PAGE 

Neoplasms,  evolution  of 12 

growth  of 21 

infiltrations  of 22 

malignant 6 

recurrent 8 

spontaneous  disappearance  of. .  216 

transformation  of 22 

treatment  of 216 

typical 7 

Net-celled  sarcoma 101 

Neuroma,  amy  clinic 10,  61 

Nipple,  discharge  from,  Li  adeno- 
ma    122 

discharge  from,  in  carcinoma. .  182 

discharge  from,  in  cystic  fibro- 
ma       59 

discharge  from,  in  cystic  sar- 
coma       87 

discharge  from,  in  cy.sts.. .   190,  193 

eczema  and  psoriasis  of,  relation 

of,  to  carcinoma 28,  144 

eczema  and  psoriasis  of,  relation 

of,     to    non  -  carcinomatous 

growths 31 

Non-carcinomatous  tumors 

cystic. 208 

diagnosis  of 198 

solid 208 

treatment  of 216 

Operations  on  breast,  inadequate  ...  221 

Operations  on  breast,  dressings  after .  234 

mortality  after 227 

partial 221 

thorough 219,  222,  225 

Ossifying  fibroma 53 

sarcoma 7S 

Palliative  treatment  of  carcinoma. . .  231 

Papillare  drusengeschwiilste 38,  50 

Paramammary  myxoma lOS 

Pericanalicular  tumors 38 

Pigmented  carcinoma 136, 141 

sarcoma 73 

Plasmoma 69 

Proliferous  mammary  cysts 38 

Psoriasis  of  nipple,  relation  of,  to 

carcinoma 28,  144 

relation  of,  to  non-carcinoma- 
tous growths 31 


PAGE 

Puei-pcral  mastitis,   relation    of,  to 

carcinoma 31 

relation  of,  to  non-carcinoma- 
tous growths 32 

Kadical  cure  of  carcinoma 223 

Kecurrence  of  adenoma 122 

of  carcinoma 166, 182 

of  fibroma 61 

of  myxoma 107 

of  sarcoma 94 

Eccurrent  connective  tissue  neo- 
plasms        9 

Eecurrcut  fibroid  tumor 69 

Eelative  frequency  of  tumors 9 

Eetcntion  cysts 184 

of  male  mamma 233 

Eetraction  of  nipple  in  adenoma 122 

of  nipple  in  carcinoma 147 

of  nipple  in  cysts 187,  190 

of  nipple  in  fibroma 59 

of  nipple  in  non-carcinomatous 

growths 147 

of  nipple  in  sarcoma 86 

Eetrograde  cysts 37 

Eound-cellcd  sarcoma 66 

diagnosis  of 212 

of  male  mamma 237 

prognosis  of. 90 

structure  of 66 

treatment  of 219 

Sarcoma 19,  23,  65 

adenoid 71,75 

alveolar 68 

calcifying 78 

complications  of 85 

cystic 72,  81 

cystoid 72,  77 

degenerations  of 77 

diagnosis  of 99,  211 

fungating 76 

gelatinous 101 

general  pathology  of 78 

giant-celled 70 

gross  features  of 73 

growth  of 80 

histogenesis  of 19,  65 

infection  of  contiguous  tissues 

in 88 


INDEX. 


245 


PAGE 

Sarcoma,  inflammation  of. T6 

lipomatous T^ 

lymphoid   67 

melanotic 73 

metastasis  of 9-i 

myxomatous T7 

net-celled 101 

of  male  mamma 237 

ossifying "78 

prognosis  of 90 

recurrence  of 94: 

round-celled C6 

spindle-celled 69 

telangiectatic 77 

treatment  of 219 

varieties  of 66 

Sarcomatous  carcinoma 134 

Scirrhous  carcinoma 130 

diagnosis  of 213 

disseminated 151 

disseminated,  of  male  mamma..  238 

gross  features  of 138 

minute  features  of 130 

treatment  of. 224 

Scirrhus,  atrophying,  see  Atrophying 
scirrhus. 

Scirrhus,  vesicular 38 

Sebaceous  cysts 184 

Semi-malignant  tumors 8 

Scrocystic  tumor 38 

Sexual  activity,  relation  of,  to  carci- 
noma       26 

relation  of,  to  non-carcinoma- 

tous  growths 26 

Simple  carcinoma 131 

gross  features  of 139 

minute  features  of 131 

Skin,  carcinomatous  infection  of . . . .  149 
Social  condition,  relation  of,  to  carci- 
noma      20 

relation  of,  to  non-carcinoma- 

tous  growths 26 

Soft  carcinoma,  see  Medullary  carci- 
noma. 
Solid  connective  tissue  neoplasms..     37 

Solid  fibroid  glandular  tumors 49 

Solid  non-carcinomatous  growths,  di- 
agnosis of I . . .  208 

Sorbefacient   applications   in   treat- 
ment of  tumors 217 


PAGE 

Spindle-celled  sarcoma 69 

diagnosis  of 212 

of  male  mamma 237 

prognosis  of 92 

structure  of 09 

treatment  of 21D 

Suppurating  adenoma 122 

carcinoma 142 

evolution  cysts 190 

fibroma 52 

my.xoma 105 

sarcoma 76 


Telangiectatic  adenoma 

carcinoma 

fibroma 

myxoma 

sarcoma 

Temperature,  elevation  of,  in  carci- 
noma   

elevation  of,  in  sarcoma 

Transformation  of  neoplasms 

Trauma,  relation  of,  to  carcinoma .    . 

relation  of,  to  non-carcinoma- 
tous growths 

Treatment  of  tumors  of  the  mam- 
mary gland 

Tuberous  carcinoma 

cystic  tumor 

Tubular  adenoma 112, 

carcinoma 

Tumeur  adenoide 

Tumor,  irritable 

Tumors  of  mammary  gland,  see  Neo- 
plasms. 

Tumors  of  mammary  gland,  classi- 
fication of 

definition  of 

diagnosis  of 

nomenclature  of 

of  male 

relative  frequency  of 

treatment  of. 


118 

134 

53 

103 

77 

142 
84 

23 
26 

26 

215 
132 

33 
116 
130 
110 

GO 


G 
1 

197 


237 

9 

216 


Ulceration  of  adenoma 122 

of  carcinoma 152 

of  evolution  cysts 190 

of  fibroma 52 

of  myxoma 105 


246 


INDEX. 


PAGE 

Ulceration    of    non  -  carcinomatous 

growths 153 

of  sarcoma 76 

Vascular  tumor 10 

Vegetating  carcinoma 137 

connective  tissue  neoplasms ...     40 

Vesicular  scirrhus 38 


Villous  carcinoma 137 

Wandering  cells,  relation  of,  to  tu- 
mor formation 21 

Zinc,  chloride  of,  in  treatment  of  tu- 
mors    220 


THE   END. 


D.   APPLETON   &  CO.'S 

ANNOONCEMENTS  OF  IMPORTANT  MEDICAL  WORKS. 


Now  Ready. 

A  PRACTICAL  TREATISE  ON  TUMORS  OF  THE  MAMMARY  GLAND: 

Embracing  their  Histology,  Pathology,  Diagnosis,  and    Treatment.      By 
Samuel  W.  Gross,  M.  D.,  Surgeon  to,  and  Lecturer  on  Clinical  Surgery  in, 
the  Jefferson  Medical  College  Hospital,  and  the  Philadelphia  Hospital. 
In  or\e    l:\ancisome    octavo   volume    of   about    250    pages,    witl\ 
28  Illustratior\s. 

Modern  histological  researches  have  so  utterly  revolutionized  the  entire  subject  of 
neoplasms  that  a  want  has  lon^  been  felt  for  a  concise,  accurate,  and  systematic  treatise 
on  tumors  of  the  mammary  gland.  To  fill  this  void  the  author  has  carefully  studied,  and 
illustrated  by  original  engravings,  their  minute  structure,  investigated  their  general  pa- 
thology, and  applied  the  principles  which  are  fairly  deducible  from  their  anatomy  and  hfe- 
history  to  their  differential  diagnosis  and  treatment.  Not  the  least  important  part  of  the 
work  will  he  found  to  be  that  in  which  the  view  is  defended,  and  supported  by  an  abun- 
dant array  of  facts,  that  carcinoma  maybe  permanently  relieved  by  thorough  operations 
practiced  in  the  early  stage  of  the  disease. 

Ready  in  September. 

A  NEW  AND  PRACTICAL  TREATISE  ON  THE  PRINCIPLES  AND 
PRACTICE  OF  MEDICINE. 

By  Roberts  Bartholow,  M.  A.,  M.  D.,  LL.  D.,  Professor  of  Materia  Medica 
and  General  Therapeutics  in  the  Jefferson  Medical  College  of  Philadelphia; 
recently  Professor  of  the  Practice  of  Medicine  and  of  Clinical  Medicine 
in  the  Medical  College  of  Ohio  at  Cincinnati,  etc.,  etc. 
It  will  be  ir\  one  vol.,  8vo,  and  will  contair\  about  800  pages. 

Nearly  Ready. 

ON  THE  BILE,  JAUNDICE,  AND  BILIOUS  DISEASES. 

By  J.  WicKHAM  Legg,  M.  D.,  F.  R.  C.  S.,  Assistant  Physician  to  St.  Bar- 
tholomew's Hospital,  and  Lecturer  on  Pathological  Anatomy  in  the  Medi- 
cal School. 
Ir\  or\e  volume.     With   Illustratior\s  ir\  Cl:\romo-lithograpl:\y. 

This  volume,  which  will  probably  contain  about  700  pages,  will  give  a  systematic 
and  complete  account  of  the  diseases  to  which  the  liver  is  subject,  with  the  latest  meth- 
ods for  their  treatment.  The  work  will  be  embellished  with  colored  plates,  illustrating 
some  of  the  appearances  of  diseased  parts. 

In.  Preparation. 

THE  SCIENCE  AND  ART  OF  MIDWIFERY. 

By  William  T.  Lusk,  M.  D.,  Professor  of  Obstetrics  and  Diseases  of 
Women  and  Children  in  the  Bellevue  Hospital  Medical  College  ;  Obstetric 
Surgeon  to  the  Maternity  and  Emergency  Hospitals,  and  Gynaecologist  to 
the  Bellevue  Hospital. 

In  Preparation. 

A  MANUAL  OF  GYNAECOLOGICAL  OPERATIONS. 

By  James  B.  Hunter,  M.  D.,  Surgeon  to  the  New  York  State  Woman's 
Hospital,  Fellow  of  the  New  York  Obstetrical  Society,  etc.,  etc.  With 
Illustrations. 


In  Press. 

SYPHILIS  AND  MARRIAGE. 

Lectures  delivered  at  the  Saint-Louis  Hospital,  Paris,  by  Alfred  Four- 
NiER,  Professor  a  la  Faculte  de  Medecine  de  Paris ;  Medecin  de  I'Hopital 
Saint-Louis ;  Membre  de  I'Academie  de  Medecine.  Translated  by  P.  Al- 
bert Morrow,  M.  D.,  Physician  to  the  Skin  and  Venereal  Department, 
New  York  Dispensary ;  Member  New  York  Dermatological  Society. 

Noio  Beady. 

THE  WATERING  PLACES  AND    MINERAL   SPRINGS  OF   GER- 
MANY, AUSTRIA,  AND  SWITZERLAND. 

With  Notes  on  Climatic  Resorts  and  Consumption,  Sanitariums,  Peat,  Mud, 
and  Sand  Baths,  "Whey  and  Grape  Cures,  etc.      By  Edward  Gutman,  M.  D. 
Witl\  Illustratior\s,  Comparative  Tables,  and  a  Colored  Map,  ex- 
plaining tl\e  Situatior\  and  Cl:\emical  Conipositior\  of  the  Spas. 

In  Active  Preparation. 

A  TREATISE  ON  INSANITY. 

By  William  A.  Hammond,  M.  D. 

This,  the  first  systematic  work  by  an  American  author  on  insanity,  is  intended  to 
be  a  tboroujrh  exposition  of  the  subject  in  all  its  etiological,  symptomatological,  patho- 
logical, and  therapeutical  relatioLS. 

It  will  constitute  a  volume  of  about  500  pages,  octavo,  and  will  be  illustrated  with 
woodcuts  and  autotype  representations  of  the  various  types  of  mental  derangement. 

It  will  be  isBued  in  the  course  of  the  current  year. 

A  Xeio  Edition  in  Press. 

A  TREATISE  ON  THE  DISEASES  OF  THE  NERVOUS  SYSTEM. 

By  William  A.  Hammoxd,  M.  D.,  Surgeon-General  U.  S.  Army  (retired). 
Professor  of  Diseases  of  the  Mind  and  Nervovis  System,  in  the  Medical 
Department  of  the  University  of  the  City  of  New  York,  etc. 

The  sixth  edition  of  this  work  was  published  in  1876,  and  has  for  a  long  time  been 
entirely  out  of  print.  The  author  is  now  engaged  in  revising  the  whole  book,  in  re- 
writing some  or  the  chapters,  and  in  making  important  additions  so  as  to  bring  the  trea- 
tise up  lo  the  present  advanced  stage  of  neurological  medicine.  As  an  instance,  it  may 
be  stated  that  the  "new  anatomy  and  physiology"  of  the  brain,  as  established  by  the 
most  recent  studies  and  investigations,  requires  extensive  changes  in  all  the  chapters  on 
cerebral  diseases. 

As  an  incident  of  the  favor  with  which  Dr.  Hammond's  treatise  has  been  received 
abroad,  the  publishers  desire  to  state  that  very  many  copies  have  been  sold  in  Great 
Britain ;  that  it  has  been  adopted  as  the  text-book  on  the  subject  in  the  University  of 
Edinburgh ;  that  it  has  been  translated  into  French  by  Dr.  Labadie  Lagrave,  of  Paris ; 
and  that  an  Italian  translation  is  now  in  course  of  preparation,  under  the  supervision 
of  Dr.  Diodato  Borrclli,  Professor  of  the  Practice  of  Medicine  in  the  Royal  Lniversity 
of  Naples.  ^ 

The  work  will  be  published  early  in  the  autumn. 

In  Preparation  :  A  Peviscd,  Enlarged,  and  Illustrated  Edition. 
DISEASES  OF  THE  RECTUM.  ' 

By  W.  H.  Van  Burex,  A.  M.,  M.  D. 

The  cordial  reception  which  this  little  book  received  from  the  Profession  and  the  con- 
tinued demand  for  it  have  induced  the  author  and  the  publishers  to  prepare  an  enlarged 
and  suitably  illustrated  work  on  the  subject.  To  be  complete  in  one  volume,  crown  oc- 
tavo, and  issued  at  an  early  date. 

D.  APPLETON  k  CO,,  Pulilisliers,  U,  &  5  Bond  Street,  New  York. 


MEDICAL  AND  HYGIENIC  WORKS 

PUBLISHED   BY 

D.  APPLETON  &  CO.,  1,  3,  &  5  Bond  St.,  New  York. 


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System.  Delivered  by  W.  A.  Hammond,  M.  D.,  Professor  of  Dis- 
eases of  the  Mind  and  Nervous  System  in  the  University  of  the  City 
of  New  York  ;  President  of  the  New  York  Neurological  Society, 
etc.  Reported,  edited,  and  the  Histories  of  the  Cases  prepared,  with 
Notes,  by  T.  M.  B.  Cross,  M.  D.,  Assistant  to  the  Chair  of  Diseases 
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New  York ;  Member  of  the  New  York  Neurological  Society,  etc. 

8vo Cloth,     3  50* 

DAVIS    (HENRY    G.)      Conservative   Surgery.      With    Illustrations. 

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ELLIOT  (GEORGE  T.)  Obstetric  Clinic:  A  Practical  Contribution 
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FOURNIER  (ALFRED,  M.  D.)     Syphilis  and  Marriage.     Translated 

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FREY  (HEINRICH).  The  Histology  and  Histochemistry  of  Man.  A 
Treatise  on  the  Elements  of  Composition  and  Structure  of  the 
Human  Body.  By  Heinrich  Frey,  Professor  of  Medicine  in  Zurich. 
Translated  from  the  fourth  German  edition,  by  Arthur  E.  J.  Barker, 
Surgeon  to  the  City  of  Dublin  Hospital ;  Demonstrator  of  Anatomy, 
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York,  etc (New  edition  in  press.) 

•  A  Treatise  on  Insanity (In  active  preparation.) 

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1.  Exercise  and  Training. 

2.  Alcohol :  Its  Use  and  Abuse. 

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